You are the nurse caring for an elderly post-operative patient who is 12 hours post-op and is on an around-the-clock regimen with opioid pain medications scheduled every 4 hours for pain prophylaxis and management. The next dose of scheduled pain medication is due soon. When planning care for this patient, you recognize that based on their current condition and vital signs they are at the most risk for which of the following (select all that apply)?

Exhibits

The nurse questions giving the next dose of opioid medication right now due to which of the following potential complications? (Select All that Apply.)

Respiratory depression

Tachycardia

Urinary frequency

Constipation

Hypotension

Answer and Explanation

Correct Answer : A,D,E

A. Respiratory depression is a common and serious side effect of opioid medications. The patient's respiratory rate is 11 breaths per minute, which is on the low end of normal and could be further depressed by additional opioid administration, increasing the risk of respiratory compromise.
B. Tachycardia is not a typical side effect of opioids. The patient’s heart rate is 72 beats per minute, which is within normal limits, and there is no indication of tachycardia.
C. Urinary frequency is unlikely to be caused by opioids. In fact, opioids can lead to urinary retention, not frequency, and the patient's urinary output is already low (480 mL in 12 hours), suggesting potential urinary retention.
D. Constipation is a common side effect of opioid use. The patient has not had a bowel movement in three days, and absent bowel sounds suggest the possibility of opioid-induced constipation.
E. Hypotension is a known side effect of opioids. The patient’s blood pressure is 90/54, which is on the low side, indicating that further opioid administration could exacerbate hypotension.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Hypertension and headache are not typical signs of hypermagnesemia. These symptoms are more commonly associated with conditions like hypertension or intracranial pressure.
B. Tachycardia and tachypnea are not characteristic of hypermagnesemia. In fact, hypermagnesemia typically causes bradycardia and hypoventilation due to the depressant effect of magnesium on the cardiovascular and respiratory systems.
C. Depressed deep tendon reflexes are a classic sign of hypermagnesemia. Magnesium sulfate acts as a central nervous system depressant, and elevated magnesium levels can impair neuromuscular function, leading to reduced reflexes.
D. Positive Trousseau's sign is indicative of hypocalcemia, not hypermagnesemia. It is a sign of low calcium levels, where a blood pressure cuff inflated above systolic pressure for 3 minutes causes muscle spasms in the hand and forearm.

A. Impaired perineal skin integrity B. Protein-calorie malnutrition C. Pain related to abdominal cramping D. Fluid and electrolyte imbalance

Correct Answer is D

Explanation

A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client receiving an infusion of IV magnesium sulfate. Which of the following findings would indicate to the nurse that the client is experiencing hypermagnesemia?

Correct Answer is C

Explanation

The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

Correct Answer is D

Explanation

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?

A nurse is providing education to a client newly prescribed Sulfasalazine and Azathioprine for refractory ulcerative colitis. Which of the following statements by the client indicates that further teaching is required?

The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?

The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?