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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Food diary shows increased consumption of iron-rich foods:

While iron-rich foods are important for managing anemia, this finding does not directly indicate the effectiveness of epoetin alfa. The primary measure of epoetin alfa's effectiveness is an improvement in hemoglobin levels, not dietary changes.

B. Reports of increased energy levels and decreased fatigue:

Increased energy and decreased fatigue are positive effects and may suggest that the medication is helping. However, these symptoms are subjective and not as definitive as a measurable increase in hemoglobin levels.

C. Takes concurrent iron therapy without adverse effects:

Iron therapy is often used alongside epoetin alfa to enhance its effectiveness, but the absence of adverse effects from iron therapy does not alone confirm the effectiveness of epoetin alfa. The key indicator is the improvement in hemoglobin levels.

D. Hemoglobin level increased to 12 g/dL (7.45 mmol/L):

An increase in hemoglobin level to 12 g/dL is a direct measure of the effectiveness of epoetin alfa. This increase demonstrates that the medication is successfully stimulating red blood cell production, which is the intended therapeutic effect.

A. Wear padding to protect from bruising if a fall occurs. B. Take measures to avoid dehydration and over-heating. C. Avoid crowds to help prevent acquiring infections. D. Keep skin and eyes covered to protect from sun injury.

Correct Answer is B

Explanation

A. Wear padding to protect from bruising if a fall occurs:
While safety precautions are important for any physical activity, the specific concern with oxybutynin is not related to a higher risk of falls or bruising. The primary issue is managing side effects that might affect hydration and body temperature.

B. Take measures to avoid dehydration and over-heating:
Oxybutynin can cause dry mouth and decreased sweating, which can increase the risk of dehydration and overheating, especially during intense physical activities like running. Emphasizing hydration and measures to avoid overheating is crucial to prevent complications.

C. Avoid crowds to help prevent acquiring infections:
Oxybutynin does not typically affect the immune system or increase the risk of infections. The client’s concern should focus on managing side effects related to exercise and hydration, rather than avoiding crowds.

D. Keep skin and eyes covered to protect from sun injury:
Oxybutynin does not have a direct effect on sun sensitivity or increase the risk of sunburn. While sun protection is generally important for outdoor activities, it is not a specific concern related to the use of oxybutynin.

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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 client with anemia secondary to chronic kidney disease (CKD) started a prescription for epoetin alfa two months ago. Which client finding best indicates that the medication is effective? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dl. (8.7 to 11.2 mmol/L)]

Correct Answer is D

Explanation

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a half-marathon. Which instruction should the nurse emphasize?

Correct Answer is B

Explanation

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