Which nursing intervention has priority when initiating a continuous epidural infusion with an opioid analgesic?

Apply a pulse oximeter to the client per protocol.

Insert an indwelling urinary catheter per protocol.

Administer an antiemetic per PRN prescription.

Administer a stool softener per PRN protocol.

Answer and Explanation

The Correct Answer is A

A) Apply a pulse oximeter to the client per protocol: The priority intervention is to monitor the client’s respiratory status closely when initiating a continuous epidural infusion with an opioid analgesic. Opioids can cause respiratory depression, and using a pulse oximeter helps in detecting any drop in oxygen saturation, allowing for timely intervention if respiratory issues arise.

B) Insert an indwelling urinary catheter per protocol: While an indwelling urinary catheter might be used in some cases for convenience and monitoring, it is not the immediate priority in the context of starting an epidural opioid infusion. The primary concern is monitoring for respiratory depression and ensuring the client’s safety with the opioid medication.

C) Administer an antiemetic per PRN prescription: Administering an antiemetic may be necessary if the client experiences nausea, which is a potential side effect of opioids. However, the more immediate concern when starting an opioid infusion is ensuring the client’s respiratory function is stable.

D) Administer a stool softener per PRN protocol: Stool softeners might be required to manage opioid-induced constipation, but this is not the most urgent concern when starting the medication. The immediate priority is monitoring respiratory status to prevent potential complications associated with opioid use.

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Correct Answer is C

Explanation

A. Hemoglobin level of 13.5 g/dL (135 g/L):
Sodium polystyrene sulfonate is used to manage hyperkalemia, not to affect hemoglobin levels. While a hemoglobin level of 13.5 g/dL is within the normal range, it does not indicate the effectiveness of sodium polystyrene sulfonate.

B. Serum ammonia level of 30 μg/dL (17.62 μmol/dL):
Sodium polystyrene sulfonate is not used to manage ammonia levels; it is used to lower elevated potassium levels. Thus, a serum ammonia level of 30 μg/dL does not reflect the effectiveness of the medication.

C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L):
Sodium polystyrene sulfonate is specifically used to treat hyperkalemia (high potassium levels). A serum potassium level of 3.8 mEq/L is within the normal range, indicating that the medication has effectively reduced elevated potassium levels.

D. Serum glucose level of 120 mg/dL (6.7 mmol/L):
Sodium polystyrene sulfonate does not affect glucose levels. A glucose level of 120 mg/dL is slightly elevated but unrelated to the effectiveness of the potassium-lowering medication.

A. Migraine headaches. B. Chronic alcoholism. C. Osteoarthritis. D. Type 2 diabetes mellitus.

Correct Answer is B

Explanation

A) Migraine headaches: While migraine headaches are significant for overall health management, they are less directly related to the risks associated with NSAID use compared to other conditions. Migraines do not typically influence the safety profile of NSAIDs.

B) Chronic alcoholism: Chronic alcoholism is a major concern because it significantly increases the risk of gastrointestinal complications with NSAID use. NSAIDs can cause gastric irritation, bleeding, and ulcers, and alcohol can exacerbate these risks, leading to severe gastrointestinal issues or liver damage.

C) Osteoarthritis: Osteoarthritis is a common indication for NSAID use and, therefore, does not pose an additional risk specific to the medication. NSAIDs are often prescribed to manage pain and inflammation associated with osteoarthritis.

D) Type 2 diabetes mellitus: Although diabetes mellitus requires careful management, it does not directly increase the risk of NSAID-related complications. However, clients with diabetes need to be monitored for overall health and medication effects, but chronic alcoholism poses a more immediate risk for NSAID use.

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Which nursing intervention has priority when initiating a continuous epidural infusion with an opioid analgesic?

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