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) 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.

A. Use relaxation techniques to reduce excessive anxiety. B. Stop taking the medication if intended effect is not immediate. C. Avoid alcohol and other sedatives while taking the medication. D. Move slowly from a sitting position to a standing position.

Correct Answer is B

Explanation

A. Use relaxation techniques to reduce excessive anxiety:
This is a good practice and complements the use of medication for managing anxiety. Relaxation techniques can help improve overall anxiety control.

B. Stop taking the medication if intended effect is not immediate:
Lorazepam, a benzodiazepine, typically starts working within hours to a few days, but it is not instantaneously effective for all individuals. Stopping the medication prematurely without consulting the healthcare provider can be harmful and is not advised. It is important to follow the prescribed regimen and consult the provider for any concerns.

C. Avoid alcohol and other sedatives while taking the medication:
This is crucial advice as combining lorazepam with alcohol or other sedatives can increase the risk of severe sedation, respiratory depression, and impaired motor skills.

D. Move slowly from a sitting position to a standing position:
This is a recommended practice to avoid dizziness or orthostatic hypotension, which can be a side effect of lorazepam and other benzodiazepines.

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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

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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