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 B

Explanation

A) Check for correct placement of the patch behind the client's ear: While ensuring correct placement is important for the effectiveness of transdermal patches, the scopolamine patch is primarily used for motion sickness and nausea, not for pain relief. Checking placement does not address the client's pain, which is not the intended use of the medication.

B) Explain that the medication is not given to prevent pain: Scopolamine is used to prevent nausea and motion sickness, not to manage pain. The client’s pain is unrelated to the patch’s intended purpose. Educating the client about the medication's purpose and recommending appropriate pain management would address the issue effectively.

C) Advise the client that the effects of the medication have worn off: The scopolamine patch's effects for nausea or motion sickness would not typically wear off within four hours. The medication was not intended to address pain, so advising the client about its effectiveness for nausea rather than pain would be more appropriate.

D) Offer to apply a new transdermal patch to relieve the pain: Applying a new patch would not be effective for pain management, as scopolamine is not designed for pain relief. Instead, the focus should be on addressing the client's pain with suitable analgesics and explaining the purpose of the scopolamine patch.

A. Adding the herb can decrease the need for corticosteroids. B. Ingestion of St. John's Wort can reduce the client's intake of sodium. C. St. John's Wort can decrease plasma concentrations of cyclosporine. D. The client probably used this herb to treat depression.

Correct Answer is C

Explanation

A) Adding the herb can decrease the need for corticosteroids: There is no substantial evidence that St. John’s Wort affects the need for corticosteroids. Its primary interactions are with medications metabolized by the liver, particularly cyclosporine, rather than affecting corticosteroid requirements directly.

B) Ingestion of St. John's Wort can reduce the client's intake of sodium: St. John’s Wort does not impact sodium intake. Its known interactions are with drugs, particularly those metabolized by the liver, rather than affecting dietary intake or sodium levels.

C) St. John's Wort can decrease plasma concentrations of cyclosporine: St. John’s Wort is a potent inducer of cytochrome P450 enzymes, which can lead to decreased plasma levels of cyclosporine, an immunosuppressant crucial for preventing graft rejection. This interaction can result in subtherapeutic levels of cyclosporine and increase the risk of graft rejection.

D) The client probably used this herb to treat depression: While it is true that St. John’s Wort is commonly used for its antidepressant effects, this is not the most significant concern in the context of a renal transplant. The primary issue is its interaction with cyclosporine, which can significantly impact transplant outcomes.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client receives a scopolamine transdermal patch 2 hours before surgery. Four hours after surgery, the client tells the nurse that he is experiencing pain and asks why the patch is not working. Which action should the nurse take?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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