NCLEX-PN® ExaminationCoordinated CareMedium
An LPN is caring for a client who is experiencing postoperative pain. The client rates their pain as an 8 on a 0-10 scale. The LPN reviews the client's medication administration record (MAR) and notes that the client is due for an opioid analgesic. Before administering the medication, which of the following actions is most important for the LPN to take?
- ACheck the client's vital signs, especially respiratory rate.
- BDocument the client's pain rating in the electronic health record (EHR).
- CEducate the client on the potential side effects of the opioid.
- DVerify the client's identity using two identifiers.
Show answer & explanationAnswer & explanation
Correct answer: A. Check the client's vital signs, especially respiratory rate.
Opioid analgesics can cause respiratory depression. Therefore, assessing the client's respiratory rate and other vital signs before administration is a critical safety measure to prevent adverse events and is a standard component of safe medication administration.
Why the other options are wrong
- B. Documenting the pain rating is important for comprehensive care, but it is a post-assessment action, not a prerequisite for safe administration.
- C. While important, educating on side effects is secondary to ensuring the client's physiological safety before administering a potent medication.
- D. Verifying client identity is a fundamental 'right' of medication administration, but the most immediate and critical safety check for an opioid is vital signs.
Opioid Administration Safety
The critical safety checks and monitoring required before and after administering opioid analgesics to prevent adverse effects, especially respiratory depression.
- Assess vital signs, especially respiratory rate.
- Monitor for sedation and respiratory depression.
- Have naloxone readily available.
Memory trick: Before giving 'PAIN' meds, 'CHECK' patient 'BREATH' and 'RESPONSE'.