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 A
Explanation
A. When signs of severe hypoglycemia occur:
Glucagon is used to rapidly increase blood glucose levels in cases of severe hypoglycemia when the person is unable to eat or drink. It is administered in emergency situations where the individual is unconscious or unable to consume oral glucose.
B. Before meals to prevent hyperglycemia:
Glucagon is not used to prevent hyperglycemia or as a routine preventive measure. It is specifically for emergency treatment of severe hypoglycemia.
C. When unable to eat during sick days:
While glucagon can be used if the person is unable to eat due to severe hypoglycemia, it is not typically used as a preventative measure for situations where the client is simply unable to eat. Regular monitoring and management of blood glucose levels are necessary during illness.
D. At the onset of signs of diabetic ketoacidosis:
Glucagon is not used to treat diabetic ketoacidosis (DKA). DKA is managed with insulin, fluids, and electrolytes, not glucagon.
Correct Answer is B
Explanation
A. The viral load can be decreased to an undetectable level:
This statement is accurate. Antiretroviral medications can reduce the viral load in the blood to undetectable levels, which helps in managing HIV effectively.
B. Antiretroviral medication prevents the transmission of the virus:
This statement is misleading. While antiretroviral medications are effective in managing HIV and can reduce the viral load to undetectable levels, they do not entirely prevent the transmission of the virus. Safe practices, including the use of condoms and pre-exposure prophylaxis (PrEP), are also necessary to reduce transmission risk.
C. The medications can decrease acquired immunodeficiency syndrome (AIDS) related complications:
This is correct. Antiretroviral therapy helps manage HIV, preventing the progression to AIDS and reducing the likelihood of complications associated with AIDS.
D. HIV infection is not cured by the antiretroviral regimen:
This is true. Current antiretroviral therapies effectively control HIV and prevent progression to AIDS, but they do not cure the infection. Ongoing treatment is necessary to maintain viral suppression and overall health.
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