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. The inhaler will be used before bed each night:
The timing of inhaler use depends on the type of medication (e.g., rescue vs. maintenance) and individual needs, not a fixed schedule like before bed. Proper use instructions usually specify whether it’s for acute symptoms or regular daily use.

B. Rinsing the mouth with water should be done after each use:
This is an important practice for inhaled corticosteroids to help prevent oral thrush and minimize side effects. It ensures that any residual medication is removed from the mouth.

C. Caffeinated beverages should be limited to two cups per day:
While caffeine may have interactions with certain medications, it is not specifically related to the use of inhalers. Therefore, this statement is less relevant to the immediate use of the inhaler.

D. To mask the taste of the medication, inhaler can be used during meals:
Using an inhaler during meals is not advised. It is important to use the inhaler as directed, typically separate from meals, to ensure proper inhalation and effectiveness of the medication.

A. A quiet, restful environment. B. A dimly lit room. C. A warm room temperature. D. Cool, humidified air.

Correct Answer is B

Explanation

A. A quiet, restful environment:
While a quiet and restful environment may be beneficial for general comfort, it does not specifically address the visual issues related to the use of mydriatic medications. Mydriatics cause pupil dilation, which can increase sensitivity to light, so a dimly lit room is more appropriate for managing light sensitivity.

B. A dimly lit room:
A dimly lit room is best for a client receiving mydriatic medication because mydriatics cause pupil dilation, which can lead to increased sensitivity to light and difficulty with bright environments. Reducing light exposure helps manage these symptoms and improve comfort.

C. A warm room temperature:
While maintaining a comfortable room temperature is important, it does not specifically address the visual discomfort caused by mydriatic medications. The primary concern here is light sensitivity, which is better managed with dim lighting rather than room temperature.

D. Cool, humidified air:
Cool, humidified air can be helpful for certain respiratory conditions or comfort but does not directly address the issue of light sensitivity associated with mydriatic medication use. The focus should be on managing light exposure rather than air quality.

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

Nursing Test Bank

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The nurse is teaching a client how to use an inhaler device. Which client statement indicates to the nurse that the client understands the instructions?

Correct Answer is B

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The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

Correct Answer is B

Explanation

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