Which postoperative client is manifesting the most serious negative effect of inadequate pain management?
1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort
2.Develops venous thromboembolism related to immobility caused by pain and discomfort
3. Refuses to participate in physical therapy because of fear of pain caused by exercises
4.Feels depressed about loss of function and hopeless about getting relief from pain
Ans: 2 Inadequate pain management for postsurgical
clients can affect quality of life, function, recovery, and
postsurgical complication; thus, all the manifestations are examples
of negative results. However, venous thromboembolism can lead to
pulmonary embolism, and this is an immediate life-threatening concern.
The nurse also needs to implement interventions to resolve unsatisfied
needs, fear of pain, and hopelessness related to pain and function.
Focus: Prioritization; Test Taking Tip: Use Maslow's hierarchy
to
identify priorities in caring for clients. Physiologic needs
are the first concern. In this case, venous thromboembolism is the
most serious physiologic
outcome secondary to inadequate pain management.
A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action?
1. Check the medication administration records for the past several days
2.Ask the nurse educator to provide in-service training about pain management.
3.Perform a complete pain assessment on the client and take a pain history
4.Have a conference with the staff nurses to assess their care of this client.
Ans: 4 The charge nurse must assess the performance
and attitude of the staff in relation to this client. After data are
gathered from the nurses, additional information can be obtained from
the records and the client as necessary. The
educator may be of
assistance if a knowledge deficit or need for performance improvement
is the problem. Focus: Supervision, Prioritization; Test
Taking
Tip: The first step of nursing process is assessment. In
this case, the charge
nurse applies nursing process to assess the
nursing staff's performance and
attitudes.
According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients? Select all that apply.
1.Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs)
for management of postoperative pain in adults and children without
contraindications
2. Surgical site-specific peripheral regional
anesthetic techniques in adults
and children for
procedures
3. Neuraxial (epidural) analgesia for major thoracic
and abdominal procedures if the client has risk for cardiac
complications or prolonged
ileus
4. Multimodal therapy that
could include opioids and nonopioid therapies, regional anesthetic
techniques, and nonpharmacologic therapies
5. Long-acting oral
opioids, especially in the immediate postoperative period,for
continuous around-the-clock relief
6. Neuraxial administration of
magnesium, benzodiazepines, neostigmine,tramadol, or ketamine is
recommended for postoperative pain
Ans: 1, 2, 3, 4 The American Pain Society in
collaboration with the American
Society of Anesthesiologists
recommendations for postoperative clients include: acetaminophen
and/or NSAIDs if there are no contraindications;
surgical
site-specific peripheral regional anesthetic for procedures; neuraxial
analgesia (also known as epidural) for major thoracic and abdominal
procedures, if client has risk for cardiac complications or prolonged
ileus; and
multimodal therapy, which includes use of different
types of medications and other therapies. Long-acting oral opioids are
not recommended in the postoperative period. Neuraxial administration
of magnesium,
benzodiazepines, neostigmine, tramadol, and
ketamine is not recommended.
Focus: Prioritization; Test Taking
Tip: Passing a test and working as a
competent nurse requires
keeping up to date with current practice guidelines.
Select all
that apply questions are particularly challenging. Read each
option
carefully and try to exclude incorrect options.
The home health nurse is interviewing an older client with a history
of mild heart failure and rheumatoid arthritis. The client reports
“feeling pretty good, except for the pain and stiffness in my joints
when I first get out of bed.”
Which member of the health care
team would be the most appropriate to aid in the client's report of pain?
1. Health care provider to review the dosage and frequency of pain
medication
2. Physical therapist for evaluation of function and
possible exercise therapy
3. Social worker to locate community
resources for complementary therapy
4. Unlicensed assistive
personnel to help client with a warm shower in the
morning
Ans: 4 One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions. Focus: Delegation.
Family members are encouraging the client to “tough out the pain” rather than risk drug addiction to opioids. The client is stoically abiding. The nurse recognizes that the sociocultural dimension of pain is the current priority for the client. Which question will the nurse ask?
1. “Where is the pain located, and does it radiate to other parts of
your
body?”
2. “How would you describe the pain, and how is
it affecting you?”
3. “What do you believe about pain medication
and drug addiction?”
4. “How is the pain affecting your activity
level and your ability to function?”
Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization.
A client with diabetic neuropathy reports a burning, electrical-type
pain in the lower extremities that is worse at night and not
responding to nonsteroidal anti-inflammatory drugs. Which medication
will the nurse
advocate for first?
1. Gabapentin
2. Corticosteroids
3. Hydromorphone
4. Lorazepam
Ans: 1 Gabapentin is an antiepileptic drug, but it is
also used to treat diabetic neuropathy. Corticosteroids are for pain
associated with inflammation. Hydromorphone is a stronger opioid, and
it is not the first choice for chronic
pain that can be managed
with other drugs. Lorazepam is an anxiolytic that may be prescribed as
an adjuvant medication. Focus: Prioritization.
Which client is most likely to receive opioids for extended periods of time?
1. A client with fibromyalgia
2. A client with phantom limb
pain in the leg
3. A client with progressive pancreatic
cancer
4. A client with trigeminal neuralgia
Ans: 3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such a scarbamazepine. Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization.
The nurse is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best?
1. Multimodal strategies
2. Standing orders by protocol
3.
Intravenous patient-controlled analgesia (PCA)
4. Opioid dosage
based on valid numerical scale
Ans: 1 Multimodal therapies for postoperative clients
include opioids and nonopioid therapies, regional anesthetic
techniques, and nonpharmacologic therapies. This approach is thought
to be the most important strategy for pain management for most
postoperative clients. Standing orders are less optimal because there
is no consideration of individual needs or characteristics. PCA is one
important element, but not all clients can manage PCA
devices.
Assessment tools are an important part of overall
management, but basing opioid dose on a numerical scale does not
consider individual client circumstances. Focus: Prioritization.
The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first?
1. Make a note in the nurse's file and continue to observe clinical
performance.
2. Refer the new nurse to the in-service education
department.
3. Quiz the nurse about knowledge of pain management
and pharmacology.
4. Give praise for documenting dose and time
and discuss documentation
deficits.
Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision.
Which clients must be assigned to an experienced RN? Select all that apply.
1. Client who was in an automobile crash and sustained multiple
injuries
2. Client with chronic back pain related to a workplace
injury
3. Client who has returned from surgery and has a chest
tube in place
4. Client with abdominal cramps related to food
poisoning
5. Client with a severe headache of unknown
origin
6. Client with chest pain who has a history of arteriosclerosis
Ans: 1, 3, 5, 6 These clients should be assigned to an experienced RN
because all have acute conditions that require close monitoring for
any developing complications. Abdominal cramps secondary to food
poisoning is an acute condition; however, the cramping, vomiting and
diarrhea are usually self-limiting. The client with chronic back pain
would be considered physically stable. Although all clients will
benefit from care provided by an experienced RN, the client with
abdominal cramps and the client with back pain could be assigned to a
new RN, an LPN/LVN, or a float nurse. Focus: Assignment;
Test
Taking Tip: To determine acuity of clients, use nursing concepts, such
as gas exchange and perfusion. Clients 1, 3, 5, and 6 could have
potential problems related to perfusion. The client with the chest
tube could also have
a potential problem related to gas exchange.
In application of the principles of pain treatment, what is the first consideration?
1. Treatment is based on client goals.
2. A multidisciplinary
approach is needed.
3. Client's perception of pain must be
accepted.
4. Drug side effects must be prevented and managed.
Ans: 3 The client must be believed, and his or her
experience of pain must be acknowledged as valid. The data gathered
via client reports can then be applied to the other options in
developing the treatment plan. Focus:
Prioritization.
The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern?
1. A 35-year-old opioid-naïve adult will receive a basal dose of
morphine via IV patient-controlled analgesia (PCA).
2. A
65-year-old adult will be discharged with a prescription for
nonsteroidal anti-inflammatory drugs (NSAIDS).
3. A 25-year-old
adult is prescribed as needed intramuscular (IM) analgesic for
pain.
4. A 45-year-old adult is taking oral fluids and foods has
orders for IV morphine.
Ans: 1 The nurse would consider questioning all of
the medication prescriptions, but the opioid-naïve adult has the
greatest immediate risk,
because use of a basal dose has been
associated with an increased incidence of respiratory depression in
opioid-naïve clients. Older adults are frequently prescribed NSAIDS;
however, they are used with caution, and the client's history should
be reviewed for potential problems, such as a history of
gastrointestinal bleeding, cardiac disease, or renal dysfunction. Many
medications such as anticoagulants, oral hypoglycemics, diuretics, and
antihypertensives can also cause adverse drug–drug interactions
with
NSAIDs. IM injections cause pain, absorption is unreliable,
and there are no advantages over other routes of administration
routes. If a client is able to tolerate oral foods and fluids, oral
medications are preferred because the
efficacy of the oral route
is equal to the IV route. Focus: Prioritization; Test Taking Tip: It
is worthwhile to study the purposes, pharmacologic actions,and side
effects of commonly used medications. Morphine is considered
the
prototype of the opioid medications. For opioid-naïve
clients, the priority concern is respiratory depression. For clients
who need opioids for long-term pain management, the primary side
effect is constipation.
Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration?
1. Client who has sharp chest pain that increases with cough and
shortness of breath
2. Client who reports excruciating lower back
pain with hematuria
3. Client who is having an acute myocardial
infarction with severe chest pain
4. Client who is having a
severe migraine with an elevated blood pressure
Ans: 3 The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain and increase venous capacitance. The other clients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent. Focus: Prioritization.
When an analgesic is titrated to manage pain, what is the priority goal?
1. Titrate to the smallest dose that provides relief with the fewest side effects.
2. Titrate upward until the client is pain free or acceptable level
is reached.
3. Titrate downward to prevent toxicity, overdose,
and adverse effects.
4. Titrate to a dosage that is adequate to
meet the client's subjective needs.
Ans: 1 The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Focus: Prioritization.
A client received as needed (PRN) morphine, lorazepam, and
cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that
the
client has a respiratory rate of 10 breaths/min. What is the
priority action?
1. Call the health care provider to obtain an order for
naloxone.
2. Assess the client's responsiveness and respiratory
status.
3. Obtain a bag-valve mask and deliver breaths at 20
breaths/min.
4. Double-check the prescription to see which drugs
were ordered.
Ans:2 The UAP has correctly reported findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on assessment findings, the other options may also be appropriate. Focus: Prioritization.
The client is diagnosed by the emergency department health care provider (HCP) with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed?
1. The HCP is considering dexamethasone to prevent reoccurrence, and
the client has type 2 diabetes.
2. The HCP is considering
subcutaneous sumatriptan, and the client took ergotamine 3 hours
ago.
3. The HCP is considering metoclopramide, and this is a
first-time migraine for the client.
4. The HCP is considering
prochlorperazine, and the client drove himself to the hospital.
Ans: 2 The American Headache Society developed recent guidelines for treatment of acute migraines. Intravenous metoclopramide and prochlorperazine and subcutaneous sumatriptan are recommended for adults who present with first-time onset of acute migraines. Sumatriptan should not be used if ergotamine, dihydroergotamine, or other triptan medication has been used in the past 24 hours because of the additive effect of narrowing of the blood vessels that could result in damage to major organs (e.g., stroke or myocardial infarction). Dexamethasone may cause increased glucose levels. Prochlorperazine can cause drowsiness. Focus: Prioritization.
Which client is at greatest risk for respiratory depression while receiving opioids for analgesia?
1. Older adult client with chronic pain related to joint
immobility
2. Client with a heroin addiction and back
pain
3. Young female client with advanced multiple
myeloma
4. Opioid-naïve adolescent with an arm fracture and
cystic fibrosis
Ans: 4 At greatest risk are older adult clients, opiate-naïve clients, and those with underlying pulmonary disease. The adolescent has two of the three risk factors. Focus: Prioritization.
A client is crying and grimacing but denies pain and refuses pain medication because “my brother is a drug addict and has ruined our lives.” What is the priority intervention for this client?
1. Encourage expression of fears and past experiences.
2.
Provide accurate information about the use of pain medication.
3.
Explain that addiction is unlikely among acute care clients.
4. Seek family assistance in resolving this problem.
Ans: 1 This client has strong beliefs and emotions related to the issue of the brother's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, and their beliefs about drug addiction may be similar to those of the client. Focus: Prioritization.
A client's opioid therapy is being tapered off, and the nurse is
watchful for signs of withdrawal. What is one of the first signs of
withdrawal?
1. Fever
2. Nausea
3. Diaphoresis
4.
Abdominal cramps
Ans: 3 Diaphoresis is one of the early signs that occurs between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal. Focus: Prioritization; Test Taking Tip: In studying for NCLEX®, pay attention to early signs of disease processes. Early detection is considered a safety measure; therefore, NCLEX® tests to determine if you can perform early identification of potential problems.
In the care of clients with pain and discomfort, which task is most
appropriate to delegate to unlicensed assistive personnel
(UAP)?
1. Assisting the client with preparation of a sitz
bath
2. Monitoring the client for signs of discomfort while
ambulating
3. Coaching the client to deep breathe during painful
procedures
4. Evaluating relief after applying a cold compress
Ans: 1 The UAP can assist the client with hygiene
issues and knows the principles of safety and comfort for this
procedure. Monitoring the client,
teaching techniques, and
evaluating outcomes are nursing responsibilities.
Focus: Delegation.
The health care provider (HCP) has ordered a placebo for a client
with chronic pain. The newly hired nurse feels very uncomfortable
administering the medication. What is the first action that the new
nurse should take?
1. Prepare the medication and hand it to the
HCP.
2. Check the hospital policy regarding the use of a
placebo.
3. Follow a personal code of ethics and refuse to
participate.
4. Contact the charge nurse for advice and suggestions.
Ans: 4 Administering placebos is generally considered
unethical. (There are circumstances, such as clinical drug research
where placebos are used, but clients are aware of that possibility.)
The charge nurse is a resource person who can help clarify the
situation and locate and review the hospital policy. If the HCP is
insistent, suggest that he or she could give the placebo. (Note:
Use
“could,” not “should,” when talking to the HCP. This provides
a small opportunity to rethink the decision. “Should” elicits a more
defensive
response.) Although following a personal ethical code
is correct, the nurse must ensure that the client is not abandoned and
that care continues. Focus: Prioritization.
For a cognitively impaired client who cannot accurately report pain,
what is the first action that the nurse should take?
1. Closely
assess for nonverbal signs such as grimacing or rocking.
2.
Obtain baseline behavioral indicators from family members.
3.
Note the time of and client's response to the last dose of
analgesic.
4. Give the maximum as needed (PRN) dose within the
minimum time frame
for relief.
Ans: 2 Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff must rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns. Focus: Prioritization.
The oncoming day shift nurse has received the shift report from the
night nurse. The day shift nurse has done a quick check on all of the
clients and has determined that all are stable and not in acute
distress. Prioritize the order in which the oncoming nurse will care
for the following clients, 1 being the first and 5 being the
last.
1. Adolescent who is alert and oriented. He was admitted 2
days ago for treatment of meningitis. He reports a continuous headache
that is partially
relieved by medication.
2. Older man who
underwent total knee replacement surgery 2 days ago. He is using the
patient-controlled analgesia (PCA) pump frequently with good relief
and occasionally asks for bolus doses.
3. Middle-aged woman who
is demanding and frequently calls for assistance.
She was
admitted for investigation of functional abdominal pain and is
scheduled for diagnostic testing this morning.
4. Older woman
with advanced Alzheimer disease who requires total care for
all
activities of daily living. She struggles during any type of nursing
care,
and it is difficult to assess her subjective symptoms. She
is awaiting transfer to a long-term care facility.
5. Young man
who was admitted with chest pain secondary to a spontaneous
pneumothorax. Today, the chest tube will be removed and the PCA pump
will be discontinued.
Ans: 5, 3, 1, 2, 4 All of the clients are in
relatively stable condition. The client with the pneumothorax has
priority because chest tubes can leak or become dislodged or blocked.
Lung sounds and respiratory effort should be
evaluated before and
after removal of the chest tube. The woman who will be leaving the
unit for diagnostic testing should be assessed and prepared, as
needed, before she leaves for the procedure. In a client with
meningitis, a headache is not unexpected, but neurologic status and
pain should be assessed. The report of postoperative pain is expected,
but this client is getting reasonable relief most of the time. Caring
for and assessing the client with Alzheimer disease is likely to be
very time consuming; caring for her last prevents delaying care for
all the others. In addition, elderly clients with dementia benefit if
the caregiver does not act rushed or hurried. Focus: Prioritization.
On the first day after surgery, a client receiving an analgesic via
patient-controlled analgesia pump reports that the pain control is
inadequate. What is the first action that the nurse should
take?
1. Deliver the bolus dose per standing order.
2.
Contact the health care provider (HCP) to increase the dose.
3.
Try nonpharmacologic comfort measures.
4. Assess the pain for
location, quality, and intensity.
Ans: 4 Assess the pain for changes in location,
quality, and intensity, as well as changes in response to medication.
This assessment will guide the next steps. Focus: Prioritization; Test
Taking Tip: During clinical rotations, you
may observe nurses
giving pain medication without performing an adequate pain assessment.
This is an error in clinical performance. In postoperative clients,
pain could signal complications, such hemorrhage, infection, or
decreased perfusion related to tissue swelling. Always assess pain
first; then make a decision about giving medication, using
nonpharmacologic methods,or contacting the HCP.
The team is providing emergency care to a client who received an
excessive dose of opioid pain medication. Which task is best to assign
to the LPN/LVN?
1. Calling the health care provider (HCP) to
report SBAR (situation,background, assessment, recommendation)
2.
Giving naloxone and evaluating response to therapy
3. Monitoring
the respiratory status for the first 30 minutes
4. Applying
oxygen per nasal cannula as ordered
Ans: 4 The LPN/LVN is well trained to administer oxygen per nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy. Focus: Assignment.
What is the best way to schedule medication for a client with
constant pain?
1. As needed (PRN) at the client's request
2.
Before painful procedures
3. IV bolus after pain
assessment
4. Around-the-clock
Ans: 4 If the pain is constant, the best schedule is
around-the-clock to provide steady analgesia and pain control. The
other options may require
higher dosages to achieve control.
Focus: Prioritization.
Which clients can be appropriately assigned to an LPN/LVN who will
function under the supervision of an RN or team leader? Select all
that apply.
1. Client who needs preoperative teaching about the
patient-controlled analgesia pump
2. Client with a leg cast who
needs neuro-circ checks and as needed (PRN) hydrocodone
3. Client
who underwent a toe amputation and has diabetic neuropathic
pain
4. Client with terminal cancer and severe pain who is
refusing medication
5. Client who reports abdominal pain after
being kicked, punched, and beaten
6. Client with arthritis who
needs scheduled pain medications and heat applications
Ans: 2, 3, 6 The clients with the cast, toe
amputation, and arthritis are in stable condition and need ongoing
assessment and pain management that are within the scope of practice
of an LPN/LVN under the supervision of an RN.
The RN should take
responsibility for preoperative teaching, and the client with terminal
cancer needs a comprehensive assessment to determine the reason for
refusal of medication. The client with trauma needs
serial
assessments to detect occult trauma. Focus: Assignment.
The nurse is caring for a client who had abdominal surgery yesterday.
The client is restless and anxious and tells the nurse that the pain
is getting worse despite the pain medication. Physical assessment
findings include the
following: temperature, 100.3°F (37.9°C);
pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood
pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch.
The nurse decides to notify the client's provider. Place the following
report information in the correct order according to the SBAR
(situation, background, assessment,
recommendation)
format.
1. “He is restless and anxious:
temperature is 100.3°F (37.9°C); pulse is 110
beats/min;
respiratory rate is 24 breaths/min; blood pressure is 140/90
mm
Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds.”
2. “He had abdominal surgery yesterday. He is on morphine via
patient-
controlled analgesia, but he says the pain is getting
progressively worse.”
3. “I have tried to make him comfortable, and he is willing to wait
until the
next scheduled dose of pain medication, but I think his
pain warrants
evaluation.”
4. “Would you like to give me an
order for any laboratory tests or additional
therapies at this
time?”
5. “Dr. S, this is Nurse J from Unit X. I’m calling about
Mr. D, who is
reporting severe abdominal pain.”
Ans: 5, 2, 1, 3, 4 Using the SBAR format, the nurse first identifies himself or herself, gives the client's name, and describes the current situation. Next, relevant background information, such as the client's diagnosis, medications, and laboratory data, is stated. The assessment includes both client assessment data that are of concern and the nurse's analysis of the situation. Finally, the nurse makes a recommendation indicating what action he or she thinks is needed. Focus: Prioritization.
Which clients can be appropriately assigned to a newly graduated RN
who has recently completed orientation? Select all that apply.
1.
Anxious client with chronic pain who frequently uses the call
button
2. Client on the second postoperative day who needs pain
medication before dressing changes
3. Client with acquired immune
deficiency syndrome who reports headache
and abdominal and
pleuritic chest pain
4. Client with chronic pain who is to be
discharged with a new surgically implanted catheter
5. Client who
is reporting pain at the site of a peripheral IV line
6. Client
with a kidney stone who needs frequent as needed (PRN) pain medication
Ans: 2, 5, 6 The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with acquired immune deficiency syndrome has complex issues that require expert assessment skills. The client pending discharge will need special and detailed instructions. Focus: Assignment.
A client's family member comes to the nurse's station and says, “He
needs more pain medicine. He is still having a lot of pain.” What is
the nurse's best response?
1. “The health care provider (HCP)
ordered the medicine to be given every 4
hours.”
2. “If
medication is given too frequently, there are ill effects.”
3.
“Please tell him that I will be right there to check on him.”
4. “Let's wait about 40 minutes. If there he still hurts, I’ll call the HCP.”
Ans: 3 Responding to the client and family in a timely fashion is important. Next, directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next. Focus:Prioritization.
Pain disorder and depression have been diagnosed for a client. He
reports chronic low back pain and states, “None of these doctors has
done anything to help.” Which client statement is cause for greatest
concern?
1. “I twisted my back last night, and now the pain is a
lot worse.”
2. “I’m so sick of this pain. I think I’m going to
find a way to end it.”
3. “Occasionally, I buy pain killers from
a guy in my neighborhood.”
4. “I’m going to sue you and the
doctor; you aren’t doing anything for me.”
Ans: 2 This statement is a veiled suicide threat, and
clients with pain disorder and depression have a high risk for
suicide. New injuries must be
evaluated, but this type of pain
report is not uncommon for clients with pain disorder. Risk for
substance abuse is very high and should eventually be addressed. The
client can always threaten to sue, but the nurse must remain
calm
and continue to provide care with professional courtesy. Focus: Prioritization.
A client has severe pain and bladder distention related to urinary
retention and possible obstruction. An experienced unlicensed
assistive personnel (UAP) states that she received training in
indwelling catheter insertion at a previous job. What task can be
delegated to this UAP?
1. Assessing the bladder distention and
the pain associated with urinary
retention
2. Inserting the
indwelling catheter after verifying her knowledge of
sterile
technique
3. Evaluating the relief of pain and
bladder distention after the catheter is
inserted
4.
Measuring the urine output after the catheter is inserted and
obtaining a
specimen
Ans: 4 Measuring output and obtaining a specimen are
within the scope of practice of the UAP. Insertion of the indwelling
catheter in this client should be done by an experienced RN because
clients with obstruction and retention
are usually very difficult
to catheterize, and the nurse must evaluate the pain response during
the procedure. The UAP's knowledge of sterile technique or catheter
insertion is not the issue. Focus: Delegation.
The nurse is caring for a young man with a history of substance abuse
who had exploratory abdominal surgery 4 days ago for a knife wound.
There is a prescription to discontinue the morphine via
patient-controlled analgesia and
to start oral pain medication.
The client begs, “Please don’t stop the morphine. My pain is really a
lot worse today than it was yesterday.” What is
the best
response?
1. “Let me stop the pump, and we can try oral pain
medication to see if it relieves the pain.”
2. “I realize that
you are scared of the pain, but we must try to wean you off the
pump.”
3. “Show me where your pain is and describe how it feels
compared with yesterday.”
4. “Let's take your vital signs; then I
will discuss your concerns with the health care provider.”
Ans: 3 Assessing the pain is the priority in this
acute care setting because
there is a risk of infection or
hemorrhage. The other options might be
appropriate based on the
assessment findings. Focus: Prioritization.
The nurse is caring for a young client with type 1 diabetes who has
sustained injuries when she tried to commit suicide by crashing her
car. Her
blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but
she refuses insulin; however, she wants the pain medication. What is
the best action?
1. Notify the charge nurse and make arrangements
to transfer to intensive care.
2. Explain significance of BG and
insulin and then call the health care provider.
3. Withhold the
pain medication until she agrees to accept the insulin.
4. Give
her the pain medication and document the refusal of the insulin.
Ans: 2 Explain that insulin is a priority because life-threatening
ketoacidosis may already be in progress. If she is already aware of
the dangers of an elevated BG level, then her refusal suggests ongoing
suicidal intent and the provider should be notified so that steps can
be taken to override her refusal (potentially a court order). A BG
level of over 600 mg/dL (33.3 mmol/L) is typically a criterion for
transfer to intensive care, but making arrangements for transfer is
time consuming, and treatment of the elevated BG should begin as soon
as possible. Withholding pain medication is unethical, and merely
documenting refusal of insulin is inappropriate because of
elevated
BG and possible ongoing suicidal intent. Focus: Prioritization.
The nurse is working with a health care provider who prescribes
opioid doses based on a specific pain intensity rating (dosing to the
numbers).
Which client circumstance is cause for greatest
concern?
1. A 73-year-old frail female client with a history of
chronic obstructive pulmonary disease is prescribed 4 mg IV morphine
for pain of 1 to 3 on a scale of 0 to 10.
2. A 25-year-old
postoperative male client with a history of opioid addiction is
prescribed one tablet of oxycodone and acetaminophen for pain of 4 to
5 on a scale of 0 to 10.
3. A 33-year-old opioid-naïve female
client who has a severe migraine headache is prescribed 5 mg IV
morphine for pain of 7 to 8 on a scale of 0 to 10.
4. A
60-year-old male with a history of rheumatoid arthritis is prescribed
one tablet of hydromorphone for pain of 5 to 6 on scale of 0 to 10.
Ans: 1 According to the American Society for Pain
Management Nursing,prescribing opioid medication based solely on pain
intensity should be prohibited because there are many other factors to
consider (e.g., age, health
conditions, medication history,
respiratory status). Age, small body mass,and underlying respiratory
disease put the 73-year-old client at greatest risk for over
medication and respiratory depression. Clients with history of opioid
addiction will have a different response to medication and may need
higher doses to achieve relief. IV morphine may actually worsen
migraine headaches, and other first-line drugs (metoclopramide and
prochlorperazine and subcutaneous sumatriptan) are more effective.
Hydromorphone is not
typically prescribed for the pain associated
with chronic of rheumatoid arthritis. Focus: Prioritization.
The nurse recognizes that there are ethical considerations in helping
clients
to achieve relief from pain. Which nursing action is the
best example of the principle of nonmaleficence?
1. Client seems
excessively sedated but continues to ask for morphine, so the nurse
conducts further assessment and seeks alternatives to opioid
medication.
2. Client has no known disease disorders and no
objective signs of poor health or injury, but reports severe pain, so
nurse advocates for pain medicine.
3. Client is older, but he is
mentally alert and demonstrates good judgment, so the nurse encourages
the client to verbalize personal goals for pain management.
4.
Client repeatedly refuses pain medication but shows grimacing
and
reluctance to move, so the nurse explains the benefits of
taking pain
medication.
Ans: 1 Non maleficence is to prevent harm. If the
client is excessively sedated, the nurse knows that giving additional
opioid medication could do
more harm than good, so the nurse
would conduct further assessments and seek alternative options for
pain relief. The client's report of pain should be believed, so based
on the principle of justice, the nurse advocates for pain medication
even though an organic cause of disease is not identified. By
encouraging the client to have a voice in her or his own pain
management
goals, the nurse is applying the principle of
autonomy. By explaining the benefits of pain medication, the nurse is
applying the principle of beneficence to help the client recognize the
balance between pain control and safety.
Focus: Prioritization.
The nurse is assessing a client who has been receiving opioid
medication via patient-controlled analgesia. What is an early sign
that alerts the nurse to a possible adverse opioid reaction?
1.
Client reports shortness of breath.
2. Client is more difficult
to arouse.
3. Client is more anxious and nervous.
4. Client
reports pain is worsening.
Ans: 2 Most adverse opioid events are preceded by an
increased level of
sedation. Focus: Prioritization.
The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain?
1. Nurse A uses a behavioral assessment tool when the client is
engaged in activities.
2. Nurse B asks a client who doesn’t speak
English to point to the location of pain.
3. Nurse C uses the
same numerical rating scale every day for the same client.
4.
Nurse D asks the daughter of a confused client to describe the
client's pain.
Ans: 3 Pain assessment is very complex, but the
consistent use of the same assessment tool is the best method. The
nurse should use all tools in
conjunction with observation,
clients’ self-report, and other assessment skills. When a client is
engaged in an activity, behavior may not accurately reflect pain.
Asking a client to point to the pain is only one part of the total
pain
assessment. Relatives of confused clients can assist the
nurse to recognize the meaning of behaviors, but they are not able to
describe pain sensations for the client. Focus: Supervision.
For which of these clients is IV morphine the first-line choice for
pain management?
1. A 33-year-old intrapartum client needs pain
relief for labor contractions.
2. A 24-year-old client reports
severe headache related to being hit in the
head.
3. A
56-year-old client reports breakthrough bone pain related to
multiple
myeloma.
4. A 73-year-old client reports chronic
pain associated with hip replacement
surgery.
Ans: 3 The client with cancer needs morphine for
symptom relief. For obstetric clients, morphine can suppress fetal
respiration and uterine
contractions, so regional or epidural
methods are preferred. For head injuries, morphine could make
evaluation of mental status more difficult. In addition, if
respirations are depressed, intracranial pressure could increase.
Opioids are
usually not the first-line choice for chronic pain,
and opioids must be used with caution in older adult clients because
of changes related to aging, such as renal clearance. In addition, use
of opioids increases risk for falls and
contributes to
constipation. Focus: Prioritization.
The client is prescribed a fentanyl patch for persistent severe pain.
Which client behavior most urgently requires correction?
1.
Frequently likes to sit in the hot tub to reduce joint
stiffness
2. Prefers to place the patch only on the upper
anterior chest wall
3. Saves and reuses the old patches when he
can’t afford new ones
4. Changes the patch every 4 days rather
than the prescribed 72 hours
Ans: 1 All of these behaviors require correction;
however, heat can increase the release of medication from the patch
and result in a sudden overdose. The client should be urged to rotate
sites to prevent irritation of the skin. Reusing
old patches and
delaying the patch changes are likely to give less than optimal pain
relief. Based on assessment of behaviors, the nurse
would
reeducate about use of the patch, help the client seek
financial resources, or develop a reminder system for patch change
intervals. Focus: Prioritization.
The home health nurse discovers that an older adult client has been
sharing his pain medication with his daughter. Despite the nurse's
warnings about the dangers of sharing, he states, “My daughter can’t
afford to see a doctor or to buy medicine, so I must give her a few of
my pain pills.” Which member of the health care team is the nurse most
likely to consult first?
1. Health care provider to renew the
prescription so that client has enough
medicine
2.
Pharmacist to monitor the frequency of the prescription
refills
3. Social worker to help the family locate resources for
health care
4. Home health aide to watch for inappropriate
medication usage by family
Ans: 3 If the social worker can assist the family to
find affordable alternatives, then the father is more likely to stop
giving his medication to the
daughter. Focus: Prioritization.
For a postoperative client, the health care provider (HCP) prescribed
multimodal therapy, which includes acetaminophen, nonsteroidal
anti-
inflammatory drugs, as needed (PRN) opioids, and
nonpharmaceutical interventions. The client continuously asks for the
PRN opioid, and the nurse suspects that the client may have a drug
abuse problem. Which action by the nurse is best?
1. Administer
acetaminophen and spend extra time with the client.
2. Explain
that opioid medication is reserved for moderate to severe
pain.
3. Give the opioid because client deserves relief and drug
abuse is unconfirmed.
4. Ask the HCP to validate suspicions of
drug abuse and alter the opioid
prescription.
Ans: 3 The nurse is weighing benefit against harm. If client is a drug abuser, the medication given in the hospital is not harming him. If the client is not a drug abuser, then withholding the medication causes him to suffer pain because of unconfirmed suspicions. The nurse must also remember that medical use of opioids does not cause addiction and for clients who are addicted, withholding medication in the hospital setting does not resolve the addictive behavior. Focus: Prioritization.
An inexperienced graduate nurse is reviewing the medication
administration record (MAR) for a client who has a patient-controlled
analgesia (PCA) pump for pain management. The new nurse compares the
MAR and the health care provider's (HCP’s) prescription, and both
indicate that larger doses are prescribed at night compared with doses
throughout the day. Which member of the health care team should the
new nurse consult
first?
1. Ask the client if he typically
needs extra medication in the evening.
2. Ask the HCP to verify
that the larger amount is the correct dose.
3. Ask the pharmacist
to confirm the dosage on the original prescription.
4. Ask the
charge nurse if this is a typical dosage for nighttime PCA.
Ans: 4 The nurse has taken the first correct step and
compared the MAR to the HCP's original prescription. Because the nurse
is new, the charge nurse would be the best resource. In fact, larger
PCA doses are given at night to increase the interval between doses.
This helps the client to rest and sleep.The nurse can contact the
other members of the health care team at any time
if the charge
nurse is unable to help. Focus: Prioritization.