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)?
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.
Correct Answer is D
Explanation
A. Encouraging the client to void every 5-6 hours is not appropriate for preventing complications in chronic pyelonephritis. Regular voiding every 2-3 hours is recommended to prevent urinary stasis and bacterial growth.
B. Limiting fluid intake to 1.5L/day is counterproductive in chronic pyelonephritis, as it increases the risk of concentrated urine and urinary tract infections.
C. While decreasing sodium intake may be beneficial in other conditions, it is not directly relevant to managing chronic pyelonephritis. The focus is on maintaining adequate hydration.
D. Increasing fluid intake to at least 3 L/day helps dilute the urine, reduce bacterial concentration, and flush out the urinary system, which is essential for managing and preventing further episodes of pyelonephritis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.