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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["37.5"]
Explanation
Convert grams to milligrams: 4 grams = 4000 mg
Determine the concentration of magnesium sulfate in the solution: 4000 mg / 500 mL = 8 mg/mL
Calculate the volume needed to deliver 300 mg/hour:
300 mg/hour ÷ 8 mg/mL = 37.5 mL/hour
Therefore, the nurse should set the infusion pump to deliver 37.5 mL/hour.
Correct Answer is C
Explanation
A. Do not take the medication more than once every 8 hours:
Diphenhydramine is typically dosed every 4 to 6 hours, not just once every 8 hours. However, this instruction is less critical compared to addressing the safety concerns related to drowsiness.
B. Take the medication with food to prevent gastric upset:
Diphenhydramine is generally not known to cause significant gastric upset, so this instruction is less critical. The primary concern with diphenhydramine is its sedative effects rather than gastrointestinal issues.
C. Avoid driving, since this medication causes drowsiness:
Diphenhydramine is known to cause significant drowsiness and sedation. Advising the client to avoid driving is crucial to prevent accidents and ensure their safety, making this the most important instruction.
D. Use sugarless candy or gum to help prevent a dry mouth:
While diphenhydramine can cause dry mouth, using sugarless candy or gum is a helpful but secondary instruction. The primary concern with diphenhydramine is its sedative effect, which affects the client's ability to drive safely.
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