A client has been receiving the same dose of IV opiate for 2 days to manage post-surgical pain. The client reports the drug is no longer controlling the pain. What does the nurse suspect?

Tolerance to the opiate medication is developing

There is likely a history of addiction

The client is opiate naive

Physical dependence

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Tolerance to the opiate medication is developing. This is the most likely explanation for why the client's pain is no longer being controlled by the same dose of medication. Tolerance is a physiological adaptation that occurs with repeated exposure to opioids, leading to a decrease in their effectiveness over time. This means that the client's body is becoming less responsive to the medication, and a higher dose is needed to achieve the same level of pain relief.
Choice B rationale:
There is likely a history of addiction. While it is possible that the client has a history of addiction, this is not the most likely explanation for why the medication is no longer controlling the pain. Addiction is a complex condition that is characterized by compulsive drug seeking and use, despite negative consequences. It is not simply a matter of tolerance developing.
Choice C rationale:
The client is opiate naive. This means that the client has not previously been exposed to opioids. While opiate-naive clients may be more sensitive to the effects of opioids, they are also more likely to experience side effects, such as nausea and vomiting. The fact that the client has been receiving the same dose of medication for 2 days without experiencing side effects suggests that they are not opiate naive.
Choice D rationale:
Physical dependence. Physical dependence is a state of adaptation that occurs with repeated exposure to opioids, leading to withdrawal symptoms if the medication is abruptly stopped. However, physical dependence does not necessarily mean that the medication is no longer effective in controlling pain.

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Correct Answer is B

Explanation

Choice A rationale:
Hourly neurologic checks are not the priority intervention for a client with hypokalemia. While hypokalemia can cause neuromuscular changes, such as muscle weakness and cramps, these are not typically the most immediate or life-threatening concerns.
Cardiac monitoring is crucial to detect and manage potentially fatal arrhythmias promptly.

Neurologic checks can be implemented as part of the overall assessment and monitoring plan, but they should not supersede cardiac monitoring in this situation.
Choice C rationale:
Seizure precautions are not routinely initiated for clients with hypokalemia unless there is a specific seizure history or other neurological concerns.
Hypokalemia can cause neuromuscular irritability, but it does not directly trigger seizures in most cases. The priority remains cardiac monitoring due to the significant risk of arrhythmias.
Choice D rationale:
Administering oxygen via face mask might be considered if the client exhibits respiratory distress or hypoxemia. However, it's not the immediate priority intervention for hypokalemia without accompanying respiratory compromise.
Hypokalemia primarily affects cardiac conduction, necessitating prompt cardiac monitoring.
Oxygen therapy can be administered if clinically indicated, but it does not address the underlying electrolyte imbalance.
Rationale for the correct answer, B:
Initiating cardiac monitoring is the most crucial nursing action for a client with a serum potassium level of 2.8 mEq/L. Here's a detailed explanation:
Hypokalemia's significant cardiac effects:
Potassium is essential for normal cardiac conduction and muscle contraction. Hypokalemia disrupts the electrical activity of the heart, potentially leading to:
Arrhythmias (irregular heartbeats), including potentially fatal ones like ventricular tachycardia or fibrillation. Electrocardiogram (ECG) changes, such as ST segment depression, T wave flattening or inversion, and prominent U waves. Cardiac monitoring's role:
Continuously tracks the heart's electrical activity. Enables early detection of arrhythmias.
Facilitates prompt intervention to prevent life-threatening complications. Specific benefits of cardiac monitoring in hypokalemia:

Allows for early identification and treatment of arrhythmias, potentially preventing cardiac arrest. Guides electrolyte replacement therapy, ensuring appropriate potassium administration.
Assesses the effectiveness of interventions, ensuring the patient's stability.

A. Dehydration can lead to incontinence. B. Take your diuretic in the morning. C. Have a drink every 1 to 2 hours. D. Reduce some sodium from your diet.

Correct Answer is C

Explanation

Choice A rationale:
While it's true that dehydration can lead to incontinence, simply stating this fact to the patient doesn't directly address the issue of dehydration. It doesn't provide actionable steps to correct the dehydration.
Incontinence can be a result of dehydration, but addressing the dehydration is the primary concern to prevent further complications.
Providing information about incontinence might be helpful in other contexts, but it's not the most effective advice to address mild dehydration in this specific scenario.
Choice B rationale:
Diuretics promote fluid loss through urination, which can worsen dehydration.
Advising the patient to take a diuretic in the morning would be counterproductive in this case. The goal is to increase fluid intake, not further deplete fluid levels.
It's important to consider the patient's medications and potential interactions before suggesting any changes to their medication regimen.

Choice C rationale:
Regular fluid intake is essential for maintaining hydration and replenishing lost fluids.
This advice directly addresses the issue of dehydration by encouraging the patient to consume fluids consistently. Drinking fluids every 1 to 2 hours can help restore fluid balance and prevent further complications.
It's a simple, actionable, and effective measure to address mild dehydration.
Choice D rationale:
While reducing sodium intake can be beneficial for some individuals with hypertension or other conditions, it's not the most relevant advice for addressing mild dehydration.
Sodium restriction might be appropriate in certain cases, but it doesn't directly address the immediate need to increase fluid intake.
The primary focus in this situation should be on replenishing fluids, not restricting sodium.

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A client has been receiving the same dose of IV opiate for 2 days to manage post-surgical pain. The client reports the drug is no longer controlling the pain. What does the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a client’s laboratory results and notes the serum potassium level is 2.8 mEq/L. Which nursing action should be initiated immediately?

Correct Answer is B

Explanation

A nurse is caring for an older patient admitted with mild dehydration. What advice should the nurse give to best address this issue?

Correct Answer is C

Explanation

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