Which nursing intervention has priority when initiating a continuous epidural infusion with an opioid analgesic?

Apply a pulse oximeter to the client per protocol.

Insert an indwelling urinary catheter per protocol.

Administer an antiemetic per PRN prescription.

Administer a stool softener per PRN protocol.

Answer and Explanation

The Correct Answer is A

A) Apply a pulse oximeter to the client per protocol: The priority intervention is to monitor the client’s respiratory status closely when initiating a continuous epidural infusion with an opioid analgesic. Opioids can cause respiratory depression, and using a pulse oximeter helps in detecting any drop in oxygen saturation, allowing for timely intervention if respiratory issues arise.

B) Insert an indwelling urinary catheter per protocol: While an indwelling urinary catheter might be used in some cases for convenience and monitoring, it is not the immediate priority in the context of starting an epidural opioid infusion. The primary concern is monitoring for respiratory depression and ensuring the client’s safety with the opioid medication.

C) Administer an antiemetic per PRN prescription: Administering an antiemetic may be necessary if the client experiences nausea, which is a potential side effect of opioids. However, the more immediate concern when starting an opioid infusion is ensuring the client’s respiratory function is stable.

D) Administer a stool softener per PRN protocol: Stool softeners might be required to manage opioid-induced constipation, but this is not the most urgent concern when starting the medication. The immediate priority is monitoring respiratory status to prevent potential complications associated with opioid use.

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Correct Answer is D

Explanation

A. Apply warm compresses to legs:
While leg cramps can be uncomfortable, addressing them with warm compresses does not address the potential underlying issues related to the client's symptoms, especially considering the possibility of more severe conditions.

B. Monitor intake and output:
Monitoring intake and output is important in managing fluid balance, especially with diuretics like furosemide. However, this action does not directly address the immediate concerns raised by symptoms like palpitations and a cough.

C. Raise the head of the bed:
Raising the head of the bed can be helpful if the client is experiencing shortness of breath or orthopnea. However, it does not address the need to evaluate cardiac function, which is crucial given the presence of palpitations and other symptoms.

D. Place on cardiac monitoring:
The client's symptoms—palpitations, cough, fatigue—could indicate significant electrolyte imbalances or cardiac issues, which are common with furosemide use. Cardiac monitoring is the most appropriate initial action to quickly identify and address any cardiac complications.

A. Hematocrit 42% (0.42 volume fraction). B. Hemoglobin 13 g/dL (8.07 mmol/L). C. Positive guaiac of stool. D. Gastric pH 2.0.

Correct Answer is C

Explanation

A. Hematocrit 42% (0.42 volume fraction):
A hematocrit of 42% is within the normal reference range for males (42% to 52%). While it is important to monitor hematocrit levels, this finding alone does not indicate an immediate issue.

B. Hemoglobin 13 g/dL (8.07 mmol/L):
A hemoglobin level of 13 g/dL is slightly below the normal range for males (14 to 18 g/dL). However, it is not critically low and may not require immediate intervention without additional context or symptoms.

C. Positive guaiac of stool:
A positive guaiac test for stool indicates the presence of occult blood in the stool, which could suggest gastrointestinal bleeding. Given the client's history of heartburn, indigestion, and use of ibuprofen (a nonsteroidal anti-inflammatory drug that can cause gastrointestinal bleeding), this finding is concerning and should be reported immediately to the healthcare provider for further evaluation and management.

D. Gastric pH 2.0:
A gastric pH of 2.0 is within the normal range for gastric acid, as the normal pH of gastric acid typically ranges from 1.5 to 3.5. This finding is expected and does not indicate an immediate problem related to the client's symptoms.

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Which nursing intervention has priority when initiating a continuous epidural infusion with an opioid analgesic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is taking furosemide reports experiencing leg cramps, a cough, feeling tired, and palpitations. Which action should the nurse take first?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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