In which case would the nurse be correct in withholding an opiate agonist?
a. Evidence of postural hypotension
b. Presence of constipation
c. Pain rating of 7 on a 0 to 10 scale
d. Respiratory rate of 10 breaths/min
ANS: D
The nurse would withhold the medication if respirations are less than 12 breaths/min. Postural hypotension is a common adverse effect that most frequently occurs when therapy is initiated. Providing for patient safety is important, but it does not warrant withholding the medication. Constipation is an expected adverse effect and does not warrant withholding an opiate agonist. A pain rating of 7 would not warrant holding an opiate agonist.
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