# A 62-year-old client with chronic low-back pain has taken sustained-release morphine 30 mg every 12 hours and scheduled acetaminophen for 3 months. Pain has decreased from 7/10 to 3/10, and walking has improved. Which actions should the nurse include in follow-up care? Select all that apply.

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> subject: Personal Hygiene  
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## Question

A 62-year-old client with chronic low-back pain has taken sustained-release morphine 30 mg every 12 hours and scheduled acetaminophen for 3 months. Pain has decreased from 7/10 to 3/10, and walking has improved. Which actions should the nurse include in follow-up care? Select all that apply.

1

Assess alertness, sedation, respiratory status, sleep-related breathing risk, and concurrent sedatives, especially after starting therapy or increasing a dose

2

Continue acetaminophen 1 g every 6 hours without reviewing the total from all products, alcohol use, liver disease, nutrition, or age-related risk

3

Increase sustained-release morphine whenever pain exceeds 4/10 so the client can remain pain free without first reassessing function or adverse effects

4

Add codeine for breakthrough pain because lower potency eliminates clinically important respiratory depression, drug interactions, and variation in metabolism

5

Assess bowel function and use an individualized scheduled stimulant or osmotic laxative regimen with appropriate hydration and activity measures

6

At follow-up, document pain, function, adverse effects, goals, adherence, and whether the benefits of opioid therapy continue to outweigh its risks

## Explanation

Ongoing opioid therapy is judged by meaningful improvement in pain and function while risks remain acceptable, not by a goal of zero pain. Reassess function, adverse effects, goals, adherence, and the benefit-risk balance at follow-up (Choice 6). Sedation and respiratory risk require assessment and client education, particularly after treatment begins or the dose rises (Choice 1). Opioid-related constipation often persists; assess bowel function and use an individualized bowel regimen that commonly includes a stimulant or osmotic laxative plus nonpharmacologic measures (Choice 5). Do not continue 4 g/day of acetaminophen automatically without reviewing all sources and hepatic and alcohol-related risks (Choice 2). Do not escalate morphine solely from a numeric score without reassessment (Choice 3). Codeine still causes opioid toxicity and has clinically important metabolic variability; it is not automatically a safer breakthrough medication (Choice 4).

## In-depth explanation

Clinical Judgment
The clinical aim of long-term opioid therapy for chronic pain is functional improvement, not the elimination of pain. The nurse uses a multidimensional assessment — numeric pain score, function, side effects, and patient-defined goals — to guide every titration decision.

Memory Tip
Opioid safety bundle = A-B-C: Assess multidimensional + Bowel regimen scheduled + Check sedation (POSS) and respiratory rate.

KR vs US
In Korea, opioid-induced constipation is often under-treated because routine scheduled laxatives are less common in chronic pain clinics. NCLEX-RN expects the nurse to start a stool softener plus a stimulant laxative on the same day the opioid is started, not after constipation appears.

## Clinical scenario

Clinical Practice Guide
The CDC 2022 Clinical Practice Guideline for Prescribing Opioids for Pain emphasizes individualized goal-setting, non-opioid first-line options, and the lowest effective opioid dose. The American Society for Pain Management Nursing recommends POSS-based sedation monitoring before each opioid dose, with respiratory rate as the late, most sensitive marker of opioid-induced respiratory depression.

Caution
The NCLEX trap is choosing the option that maximizes opioid dose to chase a zero-pain goal — chronic-pain therapy targets function, not numeric pain alone. Tolerance does not develop to opioid-induced constipation, so a scheduled bowel regimen is started early, not as needed.

## Key concepts

- **Multimodal Analgesia** — Combined use of two or more analgesic agents or techniques (acetaminophen, NSAIDs, opioids, regional anesthesia, non-pharmacological methods) targeting different pain pathways. Reduces opioid dose and side effects, and is the standard for chronic-pain care. NCLEX exam tip: when the prescription combines scheduled non-opioid plus opioid, do not discontinue the non-opioid.
- **POSS (Pasero Opioid-induced Sedation Scale)** — A 5-point scale (S, 1, 2, 3, 4) used to detect sedation before opioid-induced respiratory depression. Score 3 (frequent drowsiness, falls asleep mid-conversation) or 4 (no response) requires holding the opioid and notifying the provider. NCLEX exam tip: sedation precedes respiratory depression; check POSS and respiratory rate before each opioid dose, especially after a dose increase.
- **Opioid-induced Constipation (OIC)** — A near-universal side effect of opioid therapy with no tolerance development. Prevention requires a scheduled bowel regimen with both a stool softener (docusate) and a stimulant laxative (senna or bisacodyl) started on the same day the opioid is started. NCLEX exam tip: PRN laxatives alone are insufficient; the regimen must be scheduled and start early.

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