CHPN Pain Management Strategies 4 — Questions and Answers
Question 1: A patient with end-stage renal disease requires opioid therapy. Which opioid is SAFEST to use in this population due to its metabolite profile?
- Morphine
- Codeine
- Hydromorphone
- Fentanyl (Correct answer)
Correct answer: Fentanyl
Fentanyl is the preferred opioid in renal failure because it has inactive metabolites that do not accumulate, unlike morphine or hydromorphone.
Question 2: A palliative nurse is preparing to titrate opioids in an opioid-naive patient with severe cancer pain. What is the standard starting oral morphine dose for adults?
- 0.5 mg every 4 hours
- 5 mg every 4 hours (Correct answer)
- 20 mg every 4 hours
- 50 mg every 4 hours
Correct answer: 5 mg every 4 hours
The standard starting dose of oral immediate-release morphine in opioid-naive adults is 5 mg every 4 hours, titrated based on response.
Question 3: Which statement best describes the principle of 'opioid rotation' in palliative care?
- Alternating opioids daily to prevent tolerance
- Switching to a different opioid when analgesia is inadequate or side effects are intolerable (Correct answer)
- Using multiple opioids simultaneously
- Reducing the opioid dose by rotating to non-opioid drugs
Correct answer: Switching to a different opioid when analgesia is inadequate or side effects are intolerable
Opioid rotation involves switching to a different opioid to improve the balance between analgesia and side effects, often using incomplete cross-tolerance to achieve better control.
Question 4: A nurse is managing a patient's pain with a transdermal fentanyl patch. The patient's pain acutely worsens after 60 hours. What is the most appropriate first action?
- Replace the patch immediately and apply a new one
- Assess for fever, as hyperthermia increases fentanyl absorption and may cause toxicity
- Add an oral long-acting opioid
- Administer an oral immediate-release opioid for breakthrough pain (Correct answer)
Correct answer: Administer an oral immediate-release opioid for breakthrough pain
When transdermal fentanyl does not control breakthrough or acute pain, an immediate-release opioid should be used for rescue while patch delivery continues.
Question 5: A patient receiving intrathecal opioid therapy for refractory pain reports sudden severe headache. What serious complication should the nurse suspect first?
- Opioid toxicity
- Post-dural puncture headache or catheter migration (Correct answer)
- Rebound pain
- Opioid withdrawal
Correct answer: Post-dural puncture headache or catheter migration
Sudden severe headache in an intrathecal catheter patient suggests post-dural puncture headache or catheter migration, requiring immediate assessment.
Question 6: A palliative care nurse educates a family about the difference between physical dependence and addiction. Which statement is correct?
- Physical dependence means the patient is addicted
- Physical dependence is a normal physiologic response to opioids and does not indicate addiction (Correct answer)
- Addiction always develops with long-term opioid use
- Physical dependence is uncommon in hospice patients
Correct answer: Physical dependence is a normal physiologic response to opioids and does not indicate addiction
Physical dependence (withdrawal if opioid is abruptly stopped) is a predictable pharmacologic response and is distinct from addiction, which involves compulsive use despite harm.
Question 7: A hospice patient with liver failure requires analgesic management. Which opioid dose adjustment is most appropriate?
- Increase the dose due to reduced first-pass metabolism
- Use standard doses with no adjustment needed
- Reduce the dose and extend the dosing interval (Correct answer)
- Avoid all opioids and use NSAIDs instead
Correct answer: Reduce the dose and extend the dosing interval
Hepatic failure impairs opioid metabolism, increasing drug exposure and risk of toxicity; dose reduction and extended intervals are required.
CHPN Pain Management Strategies 4
A patient with end-stage renal disease requires opioid therapy.
Which opioid is SAFEST to use in this population due to its metabolite profile?