A nurse is caring for a patient who is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?

Respiratory rate: 10 breaths/min

Blood pressure: 110/70 mm Hg

Heart rate: 72 beats/min

Temperature: 37°C.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A) Respiratory rate: 10 breaths/min. This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.

Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.

The normal respiratory rate for adults is 12 to 20 breaths/min.

Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg. Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.

Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min. Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.

Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans. Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.

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Correct Answer is B

Explanation

The correct answer is choice B. Check the client’s allergy history.

This is because morphine sulfate is a medication that can cause severe allergic reactions in some people, such as anaphylaxis, which can be life-threatening.

Therefore, the nurse should always check the client’s allergy history before administering any medication, especially opioids.

Choice A is wrong because assessing the client’s respiratory rate is not the first action the nurse should take.

Although morphine sulfate can cause respiratory depression, which is a serious side effect that needs to be monitored, the nurse should first ensure that the client is not allergic to the medication.

Choice C is wrong because reviewing the client’s medication record is not the first action the nurse should take.

Although morphine sulfate can interact with other medications, such as sedatives, antidepressants, or alcohol, which can increase the risk of respiratory depression or overdose, the nurse should first ensure that the client is not allergic to the medication.

Choice D is wrong because verifying the dosage with another nurse is not the first action the nurse should take.

Although morphine sulfate is a high-alert medication that requires double-checking to prevent medication errors, the nurse should first ensure that the client is not allergic to the medication.

A. “I should drink plenty of fluids and eat high-fiber foods to prevent constipation.” B. “I should avoid driving or operating heavy machinery while taking this medication.” C. “I should take this medication only when I have severe pain that does not respond to other drugs.” D. “I should report any signs of an allergic reaction, such as rash, itching, or difficulty breathing.”.

Correct Answer is C

Explanation

The correct answer is choice C.The client should take this medicationregularlyas prescribed to maintain a steady level of analgesia and prevent breakthrough pain.

Taking the medication only when the pain is severe can lead to inadequate pain relief and increased side effects.

Choice A is wrong because drinking plenty of fluids and eating high-fiber foods can help prevent constipation, which is a common adverse effect of opioids.

Choice B is wrong because avoiding driving or operating heavy machinery is a safety precaution for clients taking opioids, as they can cause drowsiness and impaired judgment.

Choice D is wrong because reporting any signs of allergic reaction is an important instruction for clients taking any medication, especially opioids, which can cause severe hypersensitivity reactions.

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A nurse is caring for a patient who is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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