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 B

Explanation

A. Gastric irritation:
Gastric irritation is not a common side effect of gabapentin. While gastrointestinal symptoms can occur, they are not typically severe or indicative of a serious issue. Thus, this symptom is less critical to report immediately.

B. Rapid weight gain:
Rapid weight gain can be a significant side effect of gabapentin, potentially indicating fluid retention or other systemic issues. It is important to report this symptom, as it may require further evaluation and adjustment of the medication.

C. Sexual dysfunction:
Sexual dysfunction is not commonly reported with gabapentin. While it may affect some individuals, it is not typically a primary concern for discontinuing or altering treatment. Therefore, it is less urgent compared to other side effects.

D. Photosensitivity:
Photosensitivity is not a recognized side effect of gabapentin. The medication does not generally cause sensitivity to light, so this symptom is unlikely to be related to gabapentin use and is less critical to report immediately.

A. Food diary shows increased consumption of iron-rich foods. B. Reports of increased energy levels and decreased fatigue. C. Takes concurrent iron therapy without adverse effects. D. Hemoglobin level increased to 12 g/dL (7.45 mmol/L).

Correct Answer is D

Explanation

A. Food diary shows increased consumption of iron-rich foods:

While iron-rich foods are important for managing anemia, this finding does not directly indicate the effectiveness of epoetin alfa. The primary measure of epoetin alfa's effectiveness is an improvement in hemoglobin levels, not dietary changes.

B. Reports of increased energy levels and decreased fatigue:

Increased energy and decreased fatigue are positive effects and may suggest that the medication is helping. However, these symptoms are subjective and not as definitive as a measurable increase in hemoglobin levels.

C. Takes concurrent iron therapy without adverse effects:

Iron therapy is often used alongside epoetin alfa to enhance its effectiveness, but the absence of adverse effects from iron therapy does not alone confirm the effectiveness of epoetin alfa. The key indicator is the improvement in hemoglobin levels.

D. Hemoglobin level increased to 12 g/dL (7.45 mmol/L):

An increase in hemoglobin level to 12 g/dL is a direct measure of the effectiveness of epoetin alfa. This increase demonstrates that the medication is successfully stimulating red blood cell production, which is the intended therapeutic effect.

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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

The nurse is providing discharge instructions to a client who has been prescribed gabapentin 300 mg by mouth (PO) three times a day for postherpetic neuralgia. Which symptom should the nurse tell the client to report to the healthcare provider?

Correct Answer is B

Explanation

A client with anemia secondary to chronic kidney disease (CKD) started a prescription for epoetin alfa two months ago. Which client finding best indicates that the medication is effective? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dl. (8.7 to 11.2 mmol/L)]

Correct Answer is D

Explanation

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