Pharmacology and the Nursing
Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
TEST BANK
,QUESTION 1
Item Type: MCQ
Clinical Scenario:
A 68-year-old male patient who had a right total hip
replacement 24 hours ago is receiving hydromorphone 2 mg IV
every 4 hours PRN for severe pain. The patient rates his current
pain as 8/10 and reports nausea. The patient's vital signs are:
blood pressure 102/68 mmHg, heart rate 62 bpm, respiratory
rate 10 breaths/min, oxygen saturation 91% on room air.
Question Stem:
Which nursing action is the priority based on these assessment
findings?
Answer Options:
A. Administer the prescribed hydromorphone as ordered
B. Administer ondansetron for the nausea
C. Hold the hydromorphone and assess further
D. Apply supplemental oxygen and reposition the patient
Correct Answer:
C. Hold the hydromorphone and assess further
Comprehensive Rationale:
The correct answer is to hold the hydromorphone and assess
further due to signs of respiratory depression. Hydromorphone
,is a potent opioid analgesic that acts as a mu-opioid receptor
agonist in the central nervous system. It produces analgesia by
inhibiting ascending pain pathways and altering pain
perception, but it also causes dose-dependent respiratory
depression by reducing the responsiveness of brainstem
respiratory centers to carbon dioxide.
The patient's respiratory rate of 10 breaths/min and oxygen
saturation of 91% indicate respiratory depression, which is a
critical adverse effect of opioid administration. The normal
respiratory rate for an adult is 12-20 breaths/min; a rate below
12 breaths/min is clinically significant and warrants
intervention. The respiratory depression mechanism involves
opioid binding to mu receptors in the medullary respiratory
center, leading to decreased sensitivity to CO2 and reduced
respiratory drive.
Before administering additional opioid medication, the nurse
must complete a comprehensive respiratory assessment,
including:
• Depth and pattern of respirations
• Lung auscultation
• Level of consciousness
• Pupillary response
• Pain reassessment using a validated tool
, • Review of recent medication administration times and
doses
• Assessment of other contributing factors (age, renal
function, concurrent medications)
The nurse should implement the following interventions:
1. Stop the prescribed hydromorphone administration
2. Stimulate the patient to breathe deeply
3. Administer oxygen via nasal cannula or non-rebreather
mask as prescribed
4. Prepare to administer naloxone (Narcan) if respiratory
depression worsens
5. Notify the healthcare provider immediately
6. Monitor vital signs frequently
Distractor Analysis:
Option A (Incorrect): Administering hydromorphone as ordered
would be unsafe and could worsen respiratory depression,
potentially leading to respiratory arrest. This option reflects a
common medication error where the nurse focuses on pain
management without adequately assessing safety parameters.
The nurse must recognize that respiratory depression takes
priority over pain relief; patient safety must be addressed
before treating pain. The appropriate nursing action would be
Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
TEST BANK
,QUESTION 1
Item Type: MCQ
Clinical Scenario:
A 68-year-old male patient who had a right total hip
replacement 24 hours ago is receiving hydromorphone 2 mg IV
every 4 hours PRN for severe pain. The patient rates his current
pain as 8/10 and reports nausea. The patient's vital signs are:
blood pressure 102/68 mmHg, heart rate 62 bpm, respiratory
rate 10 breaths/min, oxygen saturation 91% on room air.
Question Stem:
Which nursing action is the priority based on these assessment
findings?
Answer Options:
A. Administer the prescribed hydromorphone as ordered
B. Administer ondansetron for the nausea
C. Hold the hydromorphone and assess further
D. Apply supplemental oxygen and reposition the patient
Correct Answer:
C. Hold the hydromorphone and assess further
Comprehensive Rationale:
The correct answer is to hold the hydromorphone and assess
further due to signs of respiratory depression. Hydromorphone
,is a potent opioid analgesic that acts as a mu-opioid receptor
agonist in the central nervous system. It produces analgesia by
inhibiting ascending pain pathways and altering pain
perception, but it also causes dose-dependent respiratory
depression by reducing the responsiveness of brainstem
respiratory centers to carbon dioxide.
The patient's respiratory rate of 10 breaths/min and oxygen
saturation of 91% indicate respiratory depression, which is a
critical adverse effect of opioid administration. The normal
respiratory rate for an adult is 12-20 breaths/min; a rate below
12 breaths/min is clinically significant and warrants
intervention. The respiratory depression mechanism involves
opioid binding to mu receptors in the medullary respiratory
center, leading to decreased sensitivity to CO2 and reduced
respiratory drive.
Before administering additional opioid medication, the nurse
must complete a comprehensive respiratory assessment,
including:
• Depth and pattern of respirations
• Lung auscultation
• Level of consciousness
• Pupillary response
• Pain reassessment using a validated tool
, • Review of recent medication administration times and
doses
• Assessment of other contributing factors (age, renal
function, concurrent medications)
The nurse should implement the following interventions:
1. Stop the prescribed hydromorphone administration
2. Stimulate the patient to breathe deeply
3. Administer oxygen via nasal cannula or non-rebreather
mask as prescribed
4. Prepare to administer naloxone (Narcan) if respiratory
depression worsens
5. Notify the healthcare provider immediately
6. Monitor vital signs frequently
Distractor Analysis:
Option A (Incorrect): Administering hydromorphone as ordered
would be unsafe and could worsen respiratory depression,
potentially leading to respiratory arrest. This option reflects a
common medication error where the nurse focuses on pain
management without adequately assessing safety parameters.
The nurse must recognize that respiratory depression takes
priority over pain relief; patient safety must be addressed
before treating pain. The appropriate nursing action would be
