Nursing 204 Lecture Exam 1 with complete solutions
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Course
Nursing 204
Institution
Nursing 204
1. Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?
A. Oxygen saturation of 95%
B. Difficulty arousing the patient
C. Respiratory rate of 10 breaths/min
D. Pain intensity r...
Nursing 204 Lecture Exam 1 with
complete solutions
1. Which of the following signs or symptoms in an opioid-naïve patient is of
greatest concern to the nurse when assessing the patient 1 hour after
administering an opioid?
A. Oxygen saturation of 95%
B. Difficulty arousing the patient
C. Respiratory rate of 10 breaths/min
D. Pain intensity rating of 5 on a scale of 0 to 10 - ANSWER- B. Difficulty arousing
the patient
Opioid-naive patients may develop a rare adverse effect of respiratory
depression, and sedation always occurs before respiratory depression.
2. A health care provider writes the following order for an opioidnaive patient who
returned from the operating room following a total hip replacement. "Fentanyl
patch 100 mcg, change every 3 days." Based on this order, the nurse takes the
following action:
A. Calls the health care provider, and questions the order
B. Applies the patch the third postoperative day
C. Applies the patch as soon as the patient reports pain
D. Places the patch as close to the hip dressing as possible - ANSWER- A. Calls
the health care provider, and questions the order
Fentanyl is 100 times more potent than morphine and not recommended for acute
postoperative pain
,3. A patient is being discharged home on an around-the-clock (ATC) opioid for
chronic back pain. Because of this order, the nurse anticipates an order for which
class of medication?
A. Stool softener
B. Stimulant laxative
C. H2 receptor blocker
D. Proton pump inhibitor - ANSWER- B. Stimulant laxative
Patients usually become tolerant to the side effects of opioids, with the exception
of constipation. Routinely administer stimulant laxatives, not simple stool
softeners, to prevent and treat constipation.
4. A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours
prn. Which part of the order does the nurse question?
A. The drug
B. The time interval
C. The dose
D. The route - ANSWER- B. The time interval
Controlled- or extended-release opioid formulations such as OxyContin are
available for administration every 8 to 12 hours ATC. Health care providers
should not order these long-acting formulations prn.
5. The nurse notices that a patient has received oxycodone/acetaminophen
(Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What
concerns the nurse the most?
A. The patient's level of pain
B. The potential for addiction
C. The amount of daily acetaminophen
D. The risk for gastrointestinal bleeding - ANSWER- C. The amount of daily
acetaminophen
The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-
hour dose is 4 g. It is often combined with opioids (e.g., oxycodone [Percocet])
because it reduces the dose of opioid needed to achieve successful pain control.
6. A patient with chronic low back pain who took an opioid around-the-clock
(ATC) for the past year decided to abruptly stop the medication for fear of
, addiction. He is now experiencing shaking chills, abdominal cramps, and joint
pain. The nurse recognizes that this patient is experiencing symptoms of:
A. Addiction.
B. Tolerance.
C. Pseudoaddiction.
D. Physical dependence. - ANSWER- D. Physical dependence.
Physical dependence is a state of adaptation that is manifested by a drug class
specific withdrawal syndrome produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the drug, and/or administration of an
antagonist.
7. After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a
patient's respiratory rate and depth are within normal limits. The nurse now plans
to implement the following action:
A. Discontinue all ordered opioids
B. Close the room door to allow the patient to recover
C. Administer the remaining naloxone over 4 minutes
D. Assess patient's vital signs every 15 minutes for 2 hours - ANSWER- D. Assess
patient's vital signs every 15 minutes for 2 hours
Reassess patients who receive naloxone every 15 minutes for 2 hours following
drug administration because the duration of the opioid may be longer than the
duration of the naloxone and respiratory depression may return.
8. Which one of the following instructions is crucial for the nurse to give to both
family members and the patient who is about to be started on a patient-controlled
analgesia (PCA) of morphine?
A. Only the patient should push the button.
B. Do not use the PCA until the pain is severe.
C. The PCA prevents overdoses from occurring.
D. Notify the nurse when the button is pushed. - ANSWER- A. Only the patient
should push the button.
Patient preparation and teaching are critical to the safe and effective use of PCA
devices. Patients need to understand PCA and be physically able to locate and
press the button to deliver the dose. Be sure to instruct family members not to
"push the button" for the patient.
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