A client has been receiving the same dose of IV opiate for 2 days to manage post-surgical pain. The client reports the drug is no longer controlling the pain. What does the nurse suspect?
Tolerance to the opiate medication is developing
There is likely a history of addiction
The client is opiate naive
Physical dependence
The Correct Answer is A
Choice A rationale:
Tolerance to the opiate medication is developing. This is the most likely explanation for why the client's pain is no longer being controlled by the same dose of medication. Tolerance is a physiological adaptation that occurs with repeated exposure to opioids, leading to a decrease in their effectiveness over time. This means that the client's body is becoming less responsive to the medication, and a higher dose is needed to achieve the same level of pain relief.
Choice B rationale:
There is likely a history of addiction. While it is possible that the client has a history of addiction, this is not the most likely explanation for why the medication is no longer controlling the pain. Addiction is a complex condition that is characterized by compulsive drug seeking and use, despite negative consequences. It is not simply a matter of tolerance developing.
Choice C rationale:
The client is opiate naive. This means that the client has not previously been exposed to opioids. While opiate-naive clients may be more sensitive to the effects of opioids, they are also more likely to experience side effects, such as nausea and vomiting. The fact that the client has been receiving the same dose of medication for 2 days without experiencing side effects suggests that they are not opiate naive.
Choice D rationale:
Physical dependence. Physical dependence is a state of adaptation that occurs with repeated exposure to opioids, leading to withdrawal symptoms if the medication is abruptly stopped. However, physical dependence does not necessarily mean that the medication is no longer effective in controlling pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
It is crucial to prioritize the patient's spouse's emotional needs and preferences during this highly stressful and sensitive situation. Offering the choice to be present during resuscitation demonstrates respect for their autonomy, promotes family- centered care, and facilitates coping mechanisms.
Key considerations supporting this approach:
Respect for Autonomy:
Patients and their loved ones have the right to make informed decisions about their care, including being present during resuscitation efforts.
Respecting this right fosters trust, empowers the spouse, and aligns with ethical principles of patient autonomy. Family-Centered Care:
Family-centered care recognizes the importance of family members in the patient's care and decision-making.
Inviting the spouse to be present demonstrates a commitment to including them in the care process and supporting their emotional needs.
Facilitating Coping Mechanisms:
Witnessing resuscitation efforts can be distressing, but it can also provide closure, acceptance, and the opportunity to say goodbye.
Some individuals find comfort in being present and actively involved, even in difficult circumstances. The nurse can provide emotional support and guidance throughout the process.
Potential Benefits of Presence:
Studies have shown that family presence during resuscitation can have positive outcomes, such as decreased anxiety and post- traumatic stress disorder (PTSD) symptoms in family members.
It may also contribute to greater satisfaction with care and a sense of peace for those who choose to be present.
Rationales for other choices:
Choice B: Requesting that the spouse sit in the waiting room may isolate them and increase their anxiety. It deprives them of the opportunity to be involved in decision-making and potentially delays their grieving process.
Choice C: While the hospital's crisis team can provide valuable support, immediate referral may not align with the spouse's immediate needs or preferences. It's essential to first assess their emotional state and offer the choice of being present.
Choice D: Suggesting prayer may be appropriate for some individuals, but it should not be the first or only option presented. It's important to respect the spouse's spiritual beliefs and offer a range of support options.
Correct Answer is C
Explanation
Choice A rationale:
While verifying the suitability of the solution for a central line is important, it is not the immediate next step after insertion. Solutions that are incompatible with central lines can cause damage to the catheter or precipitate in the bloodstream, leading to serious complications. However, confirming placement takes priority to ensure the line is correctly positioned before any infusion is initiated.
Choice B rationale:
Double-checking medication calculations is a crucial safety measure, but it is not the most urgent step after central line insertion. Medication administration can only occur after confirming proper placement to avoid unintended infusion into incorrect sites or tissues, potentially leading to tissue damage or ineffective treatment.
Choice D rationale:
Initiating the prescribed infusion via the new access is the desired outcome, but it cannot be done before confirming placement. Infusing medications or fluids through a misplaced line can have severe consequences, such as:
Infiltration of medications into surrounding tissues, causing inflammation, pain, and potential necrosis.
Administration of medications into unintended areas, such as the pleural space or the vasculature of the head and neck, leading to potentially life-threatening complications.
Delay in the delivery of necessary medications or fluids if the line is not positioned correctly within the central venous system.
Choice C rationale:
Confirming placement with an x-ray is the essential next step to ensure the central line is in the correct position within the central venous system. This verification is crucial for several reasons:
Prevention of complications: Misplaced central lines can cause serious complications, such as pneumothorax (collapsed lung), hemothorax (blood in the pleural space), arrhythmias (irregular heartbeats), and nerve damage.
Accurate medication and fluid delivery: Proper placement ensures that medications and fluids are delivered directly into the central circulation, allowing for rapid and effective distribution throughout the body.
Safe and effective infusion: X-ray confirmation provides visual evidence of the line's position, guiding subsequent infusion practices and reducing the risk of errors.
Early identification of malposition: If the x-ray reveals a misplaced line, adjustments can be made promptly to prevent potential complications and ensure appropriate infusion.
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