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 ["A","B","C"]
Explanation
A. Jugular vein distention is a common sign of fluid volume overload, as increased central venous pressure causes distention of the jugular veins.
B. Crackles heard during auscultation indicate pulmonary congestion or edema, a hallmark of fluid volume overload.
C. Dyspnea results from fluid accumulation in the lungs, impairing oxygen exchange and causing difficulty breathing.
D. Hypotension is not a sign of hypervolemia; instead, hypervolemia typically causes hypertension due to increased circulating volume.
E. Flat veins are indicative of hypovolemia, not hypervolemia. In hypervolemia, veins are typically distended due to the excess fluid volume.
Correct Answer is B
Explanation
A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.
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