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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Correct Answer is B

Explanation

A. Orthostatic hypotension can be concerning, but it is not as immediately alarming as a very elevated WBC count. It could indicate dehydration or blood loss, which are common in Crohn's disease exacerbations, but it is not as critical as an infection or severe inflammation.
B. A WBC count of 83 (normal range is typically 4,000-11,000) is significantly elevated and suggests a severe infection or inflammatory response, which is a critical concern in Crohn's disease exacerbations. This could indicate a life-threatening complication such as an abscess or perforation.
C. Lack of appetite for 2 days is common during an exacerbation of Crohn's disease, though it can contribute to dehydration or malnutrition, it is not as immediately concerning as an elevated WBC count.
D. Abdominal cramping is a typical symptom of Crohn's disease and may worsen during exacerbations, but it is not the most concerning finding compared to a severely elevated WBC count.

A. Hyperactive reflexes B. Extreme thirst C. Flattened T-wave on a 12-lead electrocardiogram (ECG). D. Hyperactive bowel sounds

Correct Answer is C

Explanation

A. Hyperactive reflexes are not typically associated with hypokalemia. In fact, hypokalemia can lead to hyporeflexia (decreased reflexes) due to the role of potassium in nerve function.
B. Extreme thirst is more commonly associated with hypernatremia or dehydration, not specifically with hypokalemia.
C. A flattened T-wave on an ECG is a classic sign of hypokalemia. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low potassium levels can cause changes in the ECG, including a flattened T-wave.
D. Hyperactive bowel sounds are typically seen in conditions like gastroenteritis or early bowel obstruction, not directly related to hypokalemia. In fact, hypokalemia can sometimes lead to hypoactive or absent bowel sounds due to its effect on smooth muscle function.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following signs and symptoms from a client who came to the clinic for an exacerbation of Crohn's Disease is the most concerning?

Correct Answer is B

Explanation

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is providing education to a patient with chronic pyelonephritis about health promotion activities. Which of the following actions should the nurse include in the teaching?

Which classification of urinary tract infection (UTI) is described as infection of the kidneys and ureters?

Which of the following actions is inappropriate when implementing precautions in a client with hyponatremia?

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 planning care for a client with type 1 diabetes mellitus. When planning administration for rapid-acting insulin Lispro, the nurse knows to administer it during which timeframe based on the onset of action?