21. A nurse is concerned that a client may be at risk for oversedation from opioid therapy using a patient-controlled analgesia pump. The most reliable assessment for possible oversedation would be to check:
21. A nurse is concerned that a client may be at risk for oversedation from opioid therapy using a patient-controlled analgesia pump. The most reliable assessment for possible oversedation would be to check:
. Changes in the level of pain reported by the client.
. The oxygen saturation level recorded by pulse oximetry.
. How easily the client can be roused from sleeping.
. The level of carbon dioxide in the blood using capnography.
Test-Taking Tip
This question is asking for the "most reliable" indication. If a client is oversedated, ventilation will be affected. Hypoventilation affects CO2.
Content Area: Adult Health, Pain Control; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Pharmacological Pain Management
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Answer 1 is incorrect because there may be improvement in the client's perception of pain; however, the concern is about oversedation by the drug. There are sedation scales available that do help the nurse identify the onset of sedation in a client. Answer 2 is incorrect because the client may be receiving supplemental oxygen. Answer 3 is incorrect because a client who is oversedated can be awakened and will respond to questions appropriately. Answer 4 is correct because opioids will depress ventilation, causing a buildup of carbon dioxide in the blood. If hypoventilation is present, measuring the level of carbon dioxide is the most reliable indication of possible respiratory depression. Capnography measures breath by breath the level of CO2 and is most often used during anesthesia, in critical care, and in emergency medicine to prevent respiratory depression. If capnography is not available with the client who is on PCA, monitoring the client's respiratory rate and depth and assessing sedation levels is essential.