Perioperative Care and Pain Management

A nurse finds that a patient with severe chronic pain has received two prescriptions: methadone an opioid, and ibuprofen, an NSAID drug. What is the likely rationale for prescribing two analgesic drugs to this patient? 1 To prevent the side effects of the opioid drug 2 To manage the side effects of the opioid drug 3 To provide better pain relief to the patient 4 To prevent the side effects of the NSAID drug

1 For treating pain in patients with chronic pain, usually an NSAID drug is prescribed along with an opioid drug. This combination helps to decrease the dose of the drug that has to be given to achieve adequate pain relief. This phenomenon is called the opioid sparing effect. This is done to prevent the side effects due to high doses of the opioid drug. NSAIDS are not added to manage the side effects of opioid drugs. Opioids do provide adequate pain relief; addition of an NSAID does not enhance its analgesic property. Opioids do not prevent the side effects of NSAID drugs. Text Reference - p. 125

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? 1 Atelectasis 2 Bronchospasm 3 Hypoventilation 4 Pulmonary embolism

1 The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions. Text Reference - p. 351

A nursing student is learning about pain medications. What does the term "analgesic ceiling" relating to nonsteroidal antiinflammatory drugs (NSAIDs) mean? Select all that apply. 1 Increasing the dose of the drug will not provide greater analgesia. Increasing the dose will produce deleterious effects on body systems. 3 There is a greater likelihood of effects related to drug interactions with NSAIDs. 4 NSAIDs would become ineffective if the drug dosage were increased beyond a particular limit. 5 The maximum dose of the medication depends on the patient's pain level.

1, 2 NSAIDs have an analgesic ceiling, which means that increasing the dose of the drug beyond a certain limit will not accentuate the analgesic effect of the drug. Overdose of certain NSAIDs has been reported to have deleterious effects. The term "analgesic ceiling" is not associated with drug interactions. The analgesic property of the NSAID drugs is not lost if the dosage is increased. There is a safe maximum dose that has been established for all medications. Text Reference - p. 125

Which manifestations would the nurse attribute to adverse effects of morphine sulfate administered by way of patient-controlled analgesia? Select all that apply. 1 Bradypnea 2 Constipation 3 Urinary retention 4 Increased blood pressure 5 Nausea and vomiting

1, 2, 3, 5 By depressing the central nervous system, the patient can develop a slowed respiratory rate. Morphine acts on the cholinergic receptors, causing urinary retention and constipation. Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor-trigger zone in the medulla. Blood pressure would decrease, not increase, because of pain control and possible sedation. Text Reference - p. 124

A nurse is assisting a postoperative patient with ambulation. What benefits of early ambulation should the nurse explain to the patient? Select all that apply. 1 It improves muscle tone. 2 It stimulates circulation. 3 It decreases vital capacity. 4 It promotes venous stasis. 5 It prevents thrombus embolism.

1, 2, 5 Early ambulation is the most significant general nursing measure to prevent postoperative complications. Early ambulation increases muscle tone and strength, and promotes venous return. This is turn improves circulation, which prevents formation of thrombus in the blood vessels. Early ambulation increases vital capacity by promoting lung expansion, and prevents venous stasis. Text Reference - p. 356

A nurse is assessing a patient in a pain clinic. The nurse observes that the patient looks pale and has an increased heart rate, blood pressure, and respiratory rate. The patient is extremely agitated. What might the nurse interpret from these findings? Select all that apply. 1 The onset of pain was sudden. 2 The pain is a type of neuropathic pain. 3 The duration of pain is less than three months. 4 The pain is a type of sympathetically maintained pain. 5 The pain is due to cardiorespiratory disease.

1, 3 Pallor, increased heart rate, blood pressure, and respiratory rate are all manifestations of acute pain. Typically, the onset of acute pain is sudden and the duration of the pain is less than three months. The cause of acute pain can be multifactorial. The nurse cannot interpret that the pain is a type of neuropathic pain. On the basis of the symptoms, the nurse cannot tell that there is underlying cardiorespiratory disease. Sympathetically maintained pain is associated with dysregulation of the autonomic nervous system. The symptoms alone do not confirm the presence of autonomic nervous system dysregulation. Text Reference - p. 121

A postoperative patient is experiencing unrelieved pain. The nurse will monitor for what possible harmful effects of unrelieved acute pain? Select all that apply. 1 Confusion 2 Hypotension 3 Hyperglycemia 4 Increased heart rate 5 Decreased respiratory rate

1, 3, 4 Possible harmful effects of unrelieved acute pain include weight loss, increased respiratory rate (not decreased), increased heart rate, hyperglycemia, hypertension (not hypotension), and confusion. Text Reference - p. 115

Which nursing interventions, according to the Pasero Opioid-Induced Sedation Scale (POSS) with Interventions, are beneficial to the patient who is drowsy and drifts to sleep during conversation following opioid therapy? Select all that apply. 1 Decreasing opioid dose 25% to 50% 2 Initiating naloxone therapy for the patient 3 Documenting the condition as acceptable to therapy 4 Administering opioid-sparing nonopioid to the patient 5 Monitoring the patient's respiratory status continuously

1, 4, 5 Frequent drowsiness and drifting off to sleep during conversation indicates that the patient is at level 3 of sedation according to the Pasero Opioid-Induced Sedation Scale (POSS). The appropriate nursing interventions at level 3 sedation are reducing the opioid dose 25% to 50% to decrease sedation, administering an opioid-sparing nonopioid such as acetaminophen or an NSAID along with the opioid, and monitoring the patient's respiratory status continuously until the sedation level is stable. Patients who are at level 4 sedation are somnolent and do not respond to verbal or physical stimulation. Naloxone is an opioid antagonist and is administered to the patient at level 4 sedation. Opioid-induced level 3 sedation is unacceptable due to the risk of life-threatening complications. Text Reference - p. 127

Which therapies will the nurse instruct the patient to follow if a primary health care provider suggests relaxation strategies in order to enhance the quality of life for a patient with chronic pain? Select all that apply. 1 Imagery 2 Exercise 3 Massage 4 Meditation 5 Art therapy

1, 4, 5 Relaxation strategies are a great way to reduce stress and anxiety, to alleviate muscle tension, to combat fatigue, and to distract from pain. Imagery is the visualization of images that help distract from pain. Meditation is a complementary therapy that induces a mode of consciousness to relieve stress associated with pain. Art therapy is the use of art media such as music, painting, and dance to distract from pain perception by exploring inner feelings. Exercise is a physical activity that enhances physical and mental fitness, particularly in the treatment of chronic pain. Massage is a physical therapy used for the treatment of acute and chronic pain. Text Reference - p. 132

An elderly postoperative patient wakes up and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. What would be important to have on the patient's plan of care? Select all that apply. 1 Use drugs to reverse the benzodiazepines. 2 Administer an antianxiety drug. 3 Administer an antipsychotic drug. 4 Administer a narcotic analgesic. 5 Ensure patient safety.

1, 5The patient's presentation of restlessness, agitation, thrashing, and shouting indicates emergence delirium. It is due to the prolonged action of opioids and benzodiazepines during the surgery. The use of opioid and benzodiazepine antagonists may reverse the effect and alleviate agitation in the patient. Until the patient is fully conscious, the nurse should ensure the patient's safety by raising the side rails of the bed and securing the equipment, such as the IV line. Antianxiety drugs are less helpful in managing emergence delirium. Emergence delirium is not a psychotic condition; therefore antipsychotic drugs are not useful. Narcotic analgesics would further enhance the action of opioids that were used during surgery. Text Reference - p. 357

The postanesthesia care unit (PACU) nurse has received a patient and all of the following assessments are included in the initial assessment. In which order should the nurse perform the following actions for the patient with no complications? Breathing Airway Neurologic Output Circulation Surgical Site Pain Gastrointestinal

1. Airway 2. Breathing 3. Circulation 4. Neurologic 5. Gastrointestinal 6. Output 7. Surgical site 8. Pain The airway, breathing, and circulation are evaluated first with vital signs, ECG, and other noninvasive methods. In the patient not experiencing surgical complications, initial neurologic assessment next will focus on level of consciousness, orientation, sensory (touch, temperature, pain) and motor status, and reactivity of pupils. The gastrointestinal system's bowel sounds will be assessed if there is no nausea and vomiting. Then output of urine and blood or wound drainage lost during surgery will be assessed for balance with the intravenous (IV) and irrigation input. The surgical site will be assessed next. Text Reference - p. 351

A patient with pancreatitis and on opioid therapy for pain relief informs the nurse of pain and difficulty in passing stools. A digital rectal examination (DRE) revealed fecal impaction. Which medication does the nurse determine to be beneficial for safe and effective care? 1 Modafinil 2 Methylnaltrexone 3 Dextroamphetamine 4 Transdermal scopolamine

2 Pain and difficulty in passing stools is associated with constipation, which is a common side effect of opioid drugs. If left untreated, it leads to fecal impaction and paralytic ileus. Methylnaltrexone is a peripheral opioid receptor antagonist used for opioid-induced constipation when the patient does not receive relief from laxative therapy. Modafinil and dextroamphetamine are psychostimulants used for persistent sedation; they are usually used in opioid-naive patients being treated for acute pain. Transdermal scopolamine is an antiemetic used for nausea, which is often a problem for opioid-naïve patients. Text Reference - p. 126

The nurse is preparing to administer medications to a patient for the management of chronic nonmalignant and cancer pain. What medications does the nurse anticipate administering? Select all that apply. 1 Baclofen 2 Duloxetine 3 Venlafaxine 4 Ropivacaine 5 Amitriptyline

2, 3, 5 Pg. 128?

A patient has undergone a major orthopedic surgery and is immobilized. On the third postoperative day, the patient reports dyspnea. On examination, the nurse finds that the patient has tachypnea, tachycardia, hypotension, and reduced oxygen saturation. How would the nurse relieve the patient of dyspnea? Select all that apply. 1 Administer lidocaine. 2 Administer oxygen therapy. 3 Administer anticoagulant therapy. 4 Administer bronchodilators. 5 Administer skeletal muscle relaxant

2 Administer oxygen therapy. 3 Administer anticoagulant therapy. Dyspnea associated with tachypnea, tachycardia, hypotension, and reduced oxygen saturation following a major orthopedic surgery indicates a pulmonary embolism. A pulmonary embolism could be a result of dislodgement of thrombus from the peripheral veins. Oxygen therapy helps improve oxygen saturation. Anticoagulant therapy prevents the blood from clotting further. Lidocaine, a local anesthetic, helps relieve laryngospasm, but may not relieve pulmonary embolism. Bronchodilators help to dilate the airways, but have no effect on embolism because it is associated with the compromised pulmonary circulation. IV skeletal muscle relaxants help relax the muscles to relieve laryngeal spasm, but do not help relieve pulmonary embolism. Text Reference - p. 352

The nurse suspects that a patient is experiencing early opioid withdrawal syndrome. Which findings did the nurse use to make this determination? Select all that apply. 1 Diarrhea 2 Rhinorrhea 3 Diaphoresis 4 Lacrimation 5 Hypertension

2, 3, 4 Manifestations of early opioid withdrawal syndrome include rhinorrhea, diaphoresis, and lacrimation. Diarrhea and hypertension are manifestations of late opioid withdrawal syndrome. Text Reference - p. 134

The patient is receiving morphine sulfate for pain. Which signs or symptoms should the nurse observe for as side effects of this medication? Select all that apply. 1 Pupil dilation 2 Urinary retention 3 Constipation 4 Decreased respiratory rate 5 Elevated blood pressure

2, 3, 4 Respiratory depression is a potentially life-threatening adverse effect of morphine sulfate, which is an opioid analgesic. It also can result in urinary retention and constipation. It would decrease blood pressure and cause pupillary constriction. Text Reference - p. 124

A patient asks the nurse why a dose of hydromorphone administered intravenous (IV) push is given before starting the medication via patient-controlled analgesia (PCA). Which response is most appropriate? 1 "PCA will never be effective unless a loading dose is given first." 2 "The IV push dose will enhance the effects of the PCA for the next eight hours." 3 "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." 4 "PCA takes at least two hours to begin working, so the IV push dose will provide pain relief in the interim."

3 An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off. Text Reference - p. 131

Which substance produced in the human body is capable of producing an analgesic effect similar to that of morphine? 1 Serotonin 2 Histamine 3 Enkephalin 4 Norepinephrine

3 Enkephalin is an endogenous opioid produced in response to noxious stimuli. It is capable of producing an analgesic effect similar to exogenous opioids such as morphine. Serotonin and histamine are chemicals released in response to stimuli to activate nociceptors during the transduction phase that do not have analgesic effects similar to those of morphine. Norepinephrine is a neurotransmitter released from affected nerve cells to inhibit activation of nearby cells in response to pain stimulus that does not exert an analgesic effect similar to that of morphine.

A 70-year-old patient is prescribed ibuprofen for back pain. Which symptom should the nurse teach the patient to be observant for? 1 Pruritus 2 Dizziness 3 Dyspepsia 4 Drowsiness

3 Ibuprofen (Motrin) is a nonsteroidal antiinflammatory drug (NSAID) that increases the risk of gastrointestinal bleeding in individuals who have a recent history of peptic ulcer disease, are older than 65, or are concurrently using corticosteroids or anticoagulants. Therefore, the nurse should teach the patient to be observant for dyspepsia as a side effect of the drug, which may indicate gastrointestinal bleeding. Drowsiness, pruritus, and dizziness are rare with ibuprofen. Text Reference - p. 124

A patient transferred to the medical-surgical unit from the postanesthesia care unit (PACU) has regained consciousness. In which position should the nurse place the patient in order to prevent respiratory problems? 1 Lithotomy position 2 Lateral recovery position 3 Supine position with head elevated 4 Prone position with extra pillows

3 If the patient is conscious, the patient should be positioned in supine position with the head elevated. This position helps to maximize the expansion of the thorax by decreasing the pressure of abdominal contents on the diaphragm. Lateral recovery position is usually used in unconscious patients to keep the airway open and reduce the risk of aspiration if vomiting occurs. Prone and lithotomy positions are not used in postsurgery patients. Text Reference - p. 354

A nurse is caring for a patient who has undergone an appendectomy. Which route of drug delivery should the nurse use to administer the opioid analgesics to treat postoperative pain? 1 Intramuscular 2 Oral 3 Intravenous 4 Intraspinal

3 Postsurgical pain requires immediate analgesia; therefore, the intravenous route is the preferable route for drug delivery. The intramuscular route is not recommended because injections cause significant pain and result in unreliable absorption. In the oral route of drug delivery, bioavailability of the drug is greatly reduced and more time is required for the analgesic effect to set in; thus, oral delivery should not be used for treating postoperative pain. Intraspinal drug delivery is a complex process with many potential complications and is not recommended for postsurgical pain. Text Reference - p. 133

Which of these is a priority for the nurse related to a patient's pain management? 1 Leave the patient alone to rest. 2 Document the patient's report of pain. 3 Assess the patient's pain. 4 Assume responsibility for eliminating the patient's pain

3 The priority for the nurse is to further assess the patient's pain. Assuming responsibility for eliminating the patient's pain, documenting the patient's report of pain, and leaving the patient to rest are correct, but not the priority. Text Reference - p. 120

Following a bowel resection, the patient is able to receive meperidine 10 mg every 10 minutes by patient-controlled analgesia (PCA) pump. What assessment data would require the nurse to take immediate action? 1 Respiratory rate 12 breaths/min, pulse 62 beats per minute 2 Pupillary dilation, blood pressure 130/98 mm Hg 3 Respiratory rate 8 breaths/min, pupillary constriction 4 Blood pressure 108/64 mm Hg, pulse 104 beats/min

3 To protect the patient from the adverse effects of respiratory depression caused by this medication, the nurse should alert the health care provider as soon as the respiratory rate drops below 12 breaths per minute. A respiratory rate of 12 is still within normal limits; papillary dilation is not associated with overdose or toxicity. The blood pressure and pulse measurements also are not indicative of overdose. Text Reference - p. 126

Which pain assessment technique should the nurse use when caring for a patient with advanced dementia? 1 Wait for the patient to express pain verbally. 2 Use a modified pain scale with large print. 3 Observe for patient behaviors that indicate pain. 4 Help the patient to use the pain thermometer scale.

3 When assessing pain in a patient with advanced dementia, the nurse should observe the patient's behavior that indicates pain. It may include grimacing, frowning, rubbing a painful area, groaning, and restlessness. The patient may have varied levels of cognitive impairment and may not be able to express pain verbally. Advanced dementia may make the patient unable to use any pain scales for rating the pain; therefore, use of pain scales or modified pain scales may not be helpful. Text Reference - p. 136

The nurse is preparing to administer cefazolin 2 gm in 100 mL of normal saline to a postoperative patient. What infusion rate on the infusion pump will infuse this medication over 20 minutes? Record your answer using a whole number. ___mL/hr

300 ml/hr Volume ÷ time in hours = rate in mL/hr. Therefore, 100 mL ÷ 0.33 hr (20 min) = 300 mL/hr. Text Reference - p. 349

Which health problem is associated with deafferentation pain? 1 Arthritis 2 Pancreatitis 3 Multiple sclerosis 4 Post-mastectomy discomfort

4 Deafferentation pain is a type of neuropathic pain that results from a loss of afferent input secondary to either peripheral nerve injury or central nervous system damage. A mastectomy is the surgical removal of breast tissue; this procedure results in a loss of afferent input. Arthritic pain arises from the bones and muscles and is an example of deep somatic pain. Pancreatitis is associated with visceral pain. Multiple sclerosis is associated with central pain. Text Reference - p. 118

The nurse is preparing to administer celecoxib 200 mg orally for pain relief. Available are capsules containing 100 mg. How many capsules should the nurse administer? Record your answer using a whole number. ___ capsules.

Dose ÷ availability = number of capsules to administer. Therefore, 200 mg ÷ 100 mg = 2 capsules. Text Reference - p. 123

The nurse is reviewing the prescriptions for a patient who is experiencing mild pain. Which of these are appropriate nonopioid analgesics for mild pain? Select all that apply. 1 Ibuprofen 2 Alprazolam 3 Oxycodone 4 Acetaminophen 5 Codeine with acetaminophen

Ibuprofen Acetaminophen Nonopioid analgesics are appropriate for mild pain, and include acetaminophen, aspirin and other salicylates, and nonsteroidal antiinflammatory drugs (NSAIDs). Alprazolam is a benzodiazepine, used for sedation or anxiety. Opioids, such as oxycodone and codeine with acetaminophen (a combination of an opioid and nonopioid), are appropriate for moderate to severe pain.

A patient has a prescription to receive oxycodone for pain. Before administering this medication, the nurse would check for which allergy that could pose a risk to the patient? 1 Penicillin 2 Morphine 3 Ibuprofen 4 Theophylline

Morphine Oxycodone is contraindicated in patients who are allergic to morphine because of possible hypersensitivity to this drug as well. There is no cross-sensitivity between oxycodone and penicillin, ibuprofen, or theophylline. Text Reference - p. 125

A nurse is reviewing the assessment data from the admission assessment of a 62-year-old male patient admitted from the emergency department. What specific element of a pain assessment is missing from the documentation? 1 Pattern 2 Quality 3 Intensity 4 Location

Quality The quality, or characteristics, of the pain is missing (e.g., cramping, stabbing, throbbing). The pattern includes the onset and duration (after eating fish and chips four hours ago). The intensity is described by "the worst pain ever!" The location is the right upper-quadrant of the abdomen, with radiation to the back. Text Reference - p. 120

A nurse is assessing a patient who has been diagnosed with sciatica. The patient states that the pain usually starts in the back and then goes to the buttocks, posterior thigh, posterior leg, and the foot. The nurse interprets the findings as which type of pain? 1 Referred pain 2 Radiating pain 3 Persistent pain 4 Breakthrough pain

Radiating pain Sciatica is a type of peripheral neuropathy that is caused by compression of or damage to the sciatic nerve. Pain in sciatica is radiating and occurs along the course of the sciatic nerve. Pain usually starts in the back and radiates downward to the buttocks, posterior thigh, posterior leg, and to the foot. A referred pain is the one in which the pain is felt in a location different from the origin of the pain. A persistent pain is less responsive to pain management therapies. A breakthrough pain is a transient, moderate to severe pain, occurring in patients who otherwise have mild to moderate pain that is fairly well controlled. Text Reference - p. 123

The patient is receiving fentanyl patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential adverse effect of this medication? 1 Hypertension 2 Pupillary dilation 3 Urinary incontinence 4 Decreased respiratory rate

Respiratory depression is a potentially life-threatening adverse effect of fentanyl, which is an opioid analgesic, via any route. Pupillary dilation, urinary incontinence, and hypertension are not potential side effects of fentanyl. Text Reference - p. 130

The patient donated a kidney and early ambulation is included in the plan of care; however, the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? "Early walking keeps your legs limber and strong." "Early ambulation will help you be ready to go home." "Early ambulation will help you get rid of your syncope and pain." "Early walking is the best way to prevent postoperative complications."

"Early walking is the best way to prevent postoperative complications."

(??) A patient is experiencing dull aching, diffuse, and radiating pain in the muscles of the right hand. Which type of pain should the nurse suspect the patient is experiencing? 1 Central 2 Visceral 3 Deep somatic 4 Superficial somatic

(??) Deep somatic pain is a type of nociceptive pain arising from muscles, bones, and tendons. This pain is either localized, or diffuse and radiating. Arthritic pain is an example of this type of pain. Central pain is a neuropathic pain caused by a primary lesion or dysfunction in the central nervous system (CNS). Poststroke pain is an example of central pain. Visceral pain is a type of nociceptive pain arising from damage to visceral organs such as those within the gastrointestinal tract and bladder. Superficial somatic pain arises from skin, mucous membranes, and subcutaneous tissue. Pain associated with sunburn is an example of superficial somatic pain. Text Reference - p. 118

Following an assessment of a patient with back pain, the nurse concludes that the patient has chronic pain. Which findings led the nurse to conclude this? Select all that apply. 1 The patient has a flat affect. 2 The patient looks agitated. 3 The patient is sweating excessively. 4 The patient's face looks pale. 5 The patient looks tired and weary

1,5 Chronic pain is pain that lasts for more than three months. Patients having chronic pain usually have a flat affect and are fatigued most of the time. Agitation, pallor, and diaphoresis (excessive sweating) are manifestations of acute pain due to stimulation of the sympathetic system. Text Reference - p. 121

(??) A drug administered for the management of pain blocks the action of the cyclooxygenase (COX) enzyme. Which phase of the nociception process is affected by the action of the drug? 1 Perception 2 Modulation 3 Transduction 4 Transmission

(??) Nociception involves four processes. Transduction is the first process, which involves the conversion of a noxious mechanical, thermal, or chemical stimulus into an electrical signal called an action potential. Drugs such as nonsteroidal antiinflammatory drugs block the action of COX and inhibit the production of prostaglandins, which are required for increased susceptibility to nociceptive activation. Hence, the drug that blocks the COX enzyme affects the transduction process. Perception is the third process that occurs when pain is recognized, defined, and assigned meaning by the individual experiencing pain. Opioids and some adjuvant drugs are used for obstructing the perception process. Modulation is the last process, which involves the activation of descending pathways that exert inhibitory or excitatory effects on the transmission of pain. Adjuvant drugs are generally used to affect modulation. Transmission, in which pain signals are relayed from the periphery to the spinal cord, and then to the brain, occurs after transduction. Text Reference - p. 116

(??) A patient in pain is anxious, fearful, and angry. Which pain dimension is this patient demonstrating? 1 Affective 2 Cognitive 3 Behavioral 4 Physiologic

(??) The biopsychosocial model of pain includes five dimensions of pain: physiologic, affective, cognitive, behavioral, and sociocultural. The affective dimension involves emotional responses to pain including anger, anxiety, fear, and depression. The cognitive dimension involves beliefs, attitudes, memories, and meaning attributed to the pain. The behavioral dimension involves the use of observable actions such as grimacing and irritability to express or control pain. The physiologic dimension involves genetic, anatomic, and physical determinants of pain. Text Reference - p. 115

A patient status postabdominal surgery is in pain and has a prescription for hydromorphone 2 mg intravenous (IV) q3h as needed (PRN). To avoid adverse effects, the nurse injecting the dose at 0800 would finish injecting the medication no earlier than which time? 1 0801 2 0802 3 0803 4 0810

0803 For this opioid analgesic to be administered safely, a 2-mg IV dose should be given over 3 to 5 minutes. If the injection began at 0800, the dose should be completed no sooner than 0803. It is acceptable to administer over 10 minutes; the minimum amount of time should be 3 minutes. Text Reference - p. 125

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, the nurse recognizes that which action best will enable the patient to achieve the desired outcomes? 1 Administering adequate analgesics to promote relief or control of pain 2 Asking the patient to demonstrate the postoperative exercises every hour 3 Giving the patient positive feedback when the activities are performed correctly 4 Warning the patient about possible complications if the activities are not performed

1 Administering adequate analgesics to promote relief or control of pain pg. 358?

A patient with osteoarthritis has been taking ibuprofen 400 mg every eight hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge? 1 Another nonsteroidal antiinflammatory drug (NSAID) may be indicated because of individual variations in response to drug therapy. 2 It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. 3 If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. 4 The patient probably is not compliant with the drug therapy and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching.

1 Another nonsteroidal antiinflammatory drug (NSAID) may be indicated because of individual variations in response to drug therapy. Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. The timeframe is not the issue in this case. Systemic corticosteroids are not the next in line for therapy; a different NSAID should be tried first. There is no evidence to ascertain any noncompliance with drug therapy. Text Reference - p. 135

A nurse educator is delivering a lecture on nociception to a group of nursing students. The nurse educator states that chemicals such as hydrogen ion and substance P play an important role in the pain pathway. What would also be appropriate for the educator to include in the teaching? 1 "These chemicals stimulate the nociceptors." 2 "These chemicals inhibit pain by acting on the anterior horn cells of the spinal cord." 3 "These chemicals inhibit transmission of the pain signal by binding to the gamma amino butyric acid (GABA) receptors." 4 "These chemicals increase the sensitivity and hyperexcitability of the neurons in the thalamus

1 Noxious stimuli cause the release of chemicals such as hydrogen ion and substance P. These substances stimulate the nociceptors. Therefore, these substances play a major role in transduction. Substance P has a stimulatory effect on anterior horn cells. Endogenous opioids like enkephalin and endorphin bind to the GABA receptors and inhibit pain transmission. These chemicals are not known to increase the sensitivity of neurons present in the thalamus. Text Reference - p. 118

The patient is due for a scheduled medication of phenytoin 50 mg intravenously (IV). The nurse should administer the dose over a minimum of how many minutes? 1 1 minute 2 2 minutes 3 5 minutes 4 10 minutes

1 Phenytoin should be given no faster than 50 mg/minute to the average adult. For a 50-mg dose, the dose should be injected over a minimum of one minute. It would also be safe to administer over 2, 5, or 10 minutes; the minimum time would be one minute. Text Reference - p. 124

Two days after colectomy for an abdominal mass, the patient reports gas pains and abdominal distension. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? 1 Slowed gastric emptying 2 Nasogastric suctioning 3 Constipation 4 Inflammation of the bowel at the anastomosis site

1 Slowed gastric emptying Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distension. Colectomy does not require a nasogastric tube; the bowel should not be inflamed following surgery unless infection is present. Constipation may occur following surgery; however, with bowel manipulation, slowed gastric emptying is the most common reason for gas pains and abdominal distention because of gas. Text Reference - p. 359

When administering an analgesic to a postoperative patient, which nursing actions should the nurse take? Select all that apply. 1 Assess the location, quality, and intensity of pain. 2 Assess the patient's sleep/wake cycle and sensory and motor status. 3 Time the analgesic administration for effectiveness during painful activities. 4 Assess the patient's level of orientation and ability to follow commands. 5 Monitor the patient for nausea, vomiting, and respiratory depression

1 Assess the location, quality, and intensity of pain. 3 Time the analgesic administration for effectiveness during painful activities. 5 Monitor the patient for nausea, vomiting, and respiratory depression When administering analgesics to a postoperative patient, the nurse should assess the location, quality, and intensity of pain. The time of administration of the analgesic should be adjusted so that the patient is free of pain during activities like ambulation. The nurse should monitor the patient for analgesic side effects, including nausea, vomiting, and respiratory depression. Assessing the sleep/wake cycle, sensory and motor status, level of orientation, and ability to follow instructions are part of a neurologic assessment and not a part of administering an analgesic. Text Reference - p. 358

A patient reports pain in the left upper limb. On assessment, a nurse finds that the pain is along the path of the brachial nerve. Based on this observation, what are the possible causes of the pain? Select all that apply. 1 Diabetes 2 Osteoarthritis 3 Heart disease 4 Alcoholism 5 Multiple sclerosis

1 Diabetes 4 Alcoholism On assessment, the nurse finds that the pain follows a dermatomal distribution. Therefore, the pain is most likely caused by damage to the peripheral nerves. Diabetes (diabetic neuropathy) and alcohol (alcohol-nutritional neuropathy) are known to cause peripheral nerve damage and can thus cause this pain. Osteoarthritis causes localized diffuse pain around the affected joint. Heart disease causes substernal pain which may be referred to the left arm, jaw, and neck. In multiple sclerosis, the primary lesion is in the brain. Peripheral nerves are not affected in multiple sclerosis. Text Reference - p. 120

A nursing student is learning about pain medications. What does the term "analgesic ceiling" relating to nonsteroidal antiinflammatory drugs (NSAIDs) mean? Select all that apply. 1 Increasing the dose of the drug will not provide greater analgesia. 2 Increasing the dose will produce deleterious effects on body systems. 3 There is a greater likelihood of effects related to drug interactions with NSAIDs. 4 NSAIDs would become ineffective if the drug dosage were increased beyond a particular limit. 5 The maximum dose of the medication depends on the patient's pain level.

1 Increasing the dose of the drug will not provide greater analgesia. 2 Increasing the dose will produce deleterious effects on body systems. NSAIDs have an analgesic ceiling, which means that increasing the dose of the drug beyond a certain limit will not accentuate the analgesic effect of the drug. Overdose of certain NSAIDs has been reported to have deleterious effects. The term "analgesic ceiling" is not associated with drug interactions. The analgesic property of the NSAID drugs is not lost if the dosage is increased. There is a safe maximum dose that has been established for all medications. Text Reference - p. 125

A patient with arthritis has been experiencing pain for four months. What other findings should the nurse expect to assess? Select all that apply. 1 Onset of pain was gradual. 2 Original cause of pain is unknown. 3 Pain severity varies from mild to severe. 4 Pain decreases over time as recovery occurs. 5 Manifestations of sympathetic system activation

1 Onset of pain was gradual. 2 Original cause of pain is unknown. 3 Pain severity varies from mild to severe. A patient experiencing pain for four months is suffering from chronic pain. The characteristics of chronic pain include a gradual or sudden onset with an unknown cause. In addition the severity of chronic pain is mild to severe. Chronic pain typically does not go away and is characterized by periods of increasing and decreasing pain. Acute pain decreases over time and goes away as recovery occurs. Manifestations of sympathetic system activation such as increased heart rate, blood pressure, and diaphoresis are associated with acute pain. Text Reference - p. 119

The nurse is reviewing the definition of pain. Which of these are correct when defining pain? Select all that apply. 1 Pain is a subjective experience. 2 Pain is a creation of a person's imagination. 3 Pain is a maladaptive response to a stimulus. 4 Pain is an unpleasant sensory and emotional experience. 5 Pain is an experience associated with actual or potential tissue damage.

1 Pain is a subjective experience. 4 Pain is an unpleasant sensory and emotional experience 5 Pain is an experience associated with actual or potential tissue damage. The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Pain is a subjective measure, in which the patient's self-report is the most valid means of assessment. Pain is not imaginary or a poor response to a stimulus. Text Reference - p. 115

Which words are often used to describe pain arising from skin, mucous membranes, and subcutaneous tissue? Select all that apply. 1 Sharp 2 Prickly 3 Burning 4 Stabbing 5 Electric shock-like

1 Sharp 2 Prickly 3 Burning Electric shock-like Superficial somatic pain arises from skin, mucous membranes, and subcutaneous tissue due to damage. Descriptors include sharp, prickling, and burning. Stabbing, shooting, and electric shock-like are expressions that are used to describe neuropathic pain.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? Select all that apply. 1 Vital signs baseline or stable 2 Minimal nausea and vomiting 3 Wants to go to the bathroom at home 4 Responsible adult taking patient home 5 Comfortable after intravenous (IV) opioid 15 minutes ago

1 Vital signs baseline or stable 2 Minimal nausea and vomiting 4 Responsible adult taking patient home Comfortable after intravenous (IV) opioid 15 minutes ago Ambulatory surgery discharge criteria include meeting Phase I postanesthesia care unit (PACU) discharge criteria, which include vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the last 30 minutes, ability to void, ability to ambulate if not contraindicated, and receiving written discharge instruction, with patient understanding confirmed. Text Reference - p. 362

The prescribed pain medication prescription reads: give hydromorphone 0.6 mg every three hours intravenous (IV) push for severe postoperative pain. The medication injection is available in a 1 mg/mL strength. How much will the nurse draw up for each dose? 1 0.2 mL 2 0.4 mL 3 0.6 mL 4 0.8 mL

3 Calculate the answer: 1 mg : 1 mL :: 0.6 mg : x m (1 × x) = (1 × 0.6); 1x = 0.6; x = 0.6; therefore the nurse will draw up 0.6 mL in the syringe. Text Reference - p. 125

A patient who has been admitted to the postoperative unit following a major abdominal surgery develops noisy respirations. On auscultation, the nurse finds coarse crackles in the lungs. How should the nurse prevent pulmonary complications in this patient? 1 By suctioning the airways 2 By providing IV hydration 3 By administering sedatives 4 By abdominal exercises 5 By administering cough suppressants

1, 2 Coarse crackles and noisy respiration are caused by increased respiratory secretions due to use of irritant anesthetic drugs. Suctioning helps clear the airway of secretions. IV hydration helps keep the secretions in liquid form, allowing them to be easily suctioned. Sedatives and cough suppressants would hinder clearing the secretions in the airways; therefore, they should not be used. Chest physical therapy, rather than abdominal exercises, would be helpful to clear secretions. Text Reference - p. 352

A nurse is caring for a patient who has undergone internal fixation surgery for fracture of the tibial shaft. The patient is on opioid drugs postsurgery to relieve postsurgical pain. On observation, the nurse finds that the patient's respiratory rate is 7 breaths per minute and the patient looks extremely drowsy. Which actions should the nurse take to prevent respiratory failure in this patient? Select all that apply. 1 Make attempts to arouse the patient. 2 Administer oxygen to the patient. 3 Obtain a prescription to discontinue opioid medications. 4 Obtain a prescription to reduce the dosage of opioid medications. 5 Obtain a prescription to administer NSAIDS instead of opioids.

1, 2, 4 Respiratory failure is a life-threatening complication associated with opioid overdose. If the patient appears drowsy and the respiratory rate is falling, the nurse should try to keep the patient awake. Oxygen should be administered to prevent hypoxia and hypoxemia. The dose of the opioid medication should be reduced to prevent any further worsening of the patient's condition. The patient has had surgery and strong pain medications are required to relieve postsurgical pain, so administration of opioids cannot be discontinued. NSAID drugs are not sufficient to relieve postsurgical pain. Text Reference - p. 128

A postoperative patient is receiving intravenous morphine. The nurse finds that the patient is drowsy and is not responding to verbal stimulation. Which actions should the nurse take? Select all that apply. 1 Monitor respiratory status 2 Monitor sedation level 3 Consider administering naloxone 4 Decrease the morphine dosage by 25% 5 Consider administering acetaminophen

1, 2,3 Respiratory distress is a major side effect of opioids, and patients on morphine should be closely monitored for their respiratory rates and sedation levels. If the patient is drowsy and nonresponsive to verbal stimuli, respiratory distress is likely. The nurse should consider administering naloxone and continue to monitor respiratory rate and sedation levels closely. The morphine should be immediately stopped and the health care provider notified. Acetaminophen is not administered when sedation level is greater than 3. Text Reference - p. 127

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions should the nurse perform? Select all that apply. 1 Give warm IV fluids. 2 Withhold opioids. 3 Use forced air warmers. 4 Use warmed cotton blankets. 5 Administer oxygen therapy.

1, 3, 4, 5 Administering warm liquids and using forced air warmers are active warming methods. Using warmed cotton blankets is a passive warming measure. Oxygen therapy is needed to meet the increased oxygen demand during shivering. Opioids are used to treat shivering in the immediate postoperative period, so the nurse should not withhold the morphine dose. Text Reference - p. 359

A nurse explains cold therapy to a patient. Which statements would be appropriate for the nurse to include? Select all that apply. 1 "Ice should not be applied over irradiated skin." 2 "You can apply ice packs directly over an open wound." 3 "Ice should be directly applied over the skin of the affected area." 4 "Ice can be applied on the contralateral side of the body over the same area." 5 "Ice should always be applied in circular motions over the affected area."

1, 4, 5 Cold therapy or heat therapy should not be used on irradiated areas because of an impaired sense of temperature in these areas. If ice application is not possible over the painful area, one could apply ice on the contralateral side of the body over the same area. Ice should not be placed static over a particular area for a long time, because it could cause ischemia. Therefore, ice should be ideally applied in circular motions over the painful area. Ice packs should not be directly applied over an open wound, because doing so can compromise the blood supply to the wound. Ice should always be covered in layers of towel or plastic before being applied to the skin. Text Reference - p. 135

A nurse educator is explaining gender differences in pain perception. Which statements made by the nurse are true? Select all that apply. 1 "Men tend to have greater control over pain." 2 "Women are less likely to report pain than men." 3 "Men experience more chronic pain than women." 4 "Women are more likely to use alternative treatments for pain." 5 "Women are more likely to be diagnosed with nonspecific somatic pain.

1, 4, 5 Males and females respond to pain differently. The threshold for pain in men is much greater than that in women. Therefore, men tend to have greater control over pain. Women get extremely preoccupied with pain and tend to use alternative and complementary therapies to get relief. Women have greater chances of being diagnosed with nonspecific pain than men. Women are more expressive about pain and related complaints. More cases of chronic pain have been reported in women than in men. Text Reference - p. 117

A patient experiences a sudden onset of severe left knee pain and is admitted to the hospital. On assessment, the nurse finds that the patient has a high blood pressure reading; however, the patient denies any history of hypertension. What may have caused the current high blood pressure reading? Select all that apply. 1 Increased antidiuretic hormone (ADH) 2 Decreased heart rate 3 Decreased production of renin 4 Increased aldosterone 5 Increased peripheral vascular resistance

1,4,5 Increased BP in a patient having acute pain could be a consequence of increased ADH. Increased levels of ADH would cause increased retention of fluid in the body, thereby increasing the blood volume. Increased aldosterone levels result in increased resorption of sodium and water from the kidneys, which results in increased blood pressure. Increased sympathetic stimulation would cause an increased resistance in the peripheral vasculature and an increase in heart rate. This would ultimately result in high blood pressure. Heart rate and blood pressure are directly proportional to each other; therefore, any increase in heart rate would cause an increase in blood pressure. Renin causes vasoconstriction so decreased production of renin would lower BP. Text Reference - p. 117

A patient is admitted to the postanesthesia care unit (PACU) after major colon surgery. During the initial assessment the patient tells the nurse he or she thinks he or she is going to "throw up." Which statement by the nurse reflects a priority nursing intervention? 1 "I need to check your vital signs." 2 "Let me help you turn to your side." 3 "Here is a sip of ginger-ale for you." 4 "I can give you some anti-nausea medicine."

2 "Let me help you turn to your side."If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side. Text Reference - p. 360

Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent? 1 Give the medication on an empty stomach. 2 Count the number of doses on hand before administration. 3 Give the medication with a glass of juice or other cold beverage. 4 Assess the patient for allergies to aspirin before administration

2 Count the number of doses on hand before administration. Because opioid analgesics are controlled substances, the nurse needs to count the number of doses and check that it matches the number recorded before removing and administering the medication. It is best to administer the opiod with food. A glass of juice or other cold beverage is not necessary. Aspirin is not in the same class as opioids, so assessing for aspirin allergies is not necessary. Text Reference - p. 133

In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that the desired outcomes are more likely if the patient: 1 Has family in the room for support and encouragement 2 Receives enough analgesics to promote relative freedom from pain 3 Is warned about pneumonia and clotting if the actions are not completed 4 Can explain easily the rationale for these activities

2 Even when a patient understands the importance of postoperative activities, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate. Warning the patient about pneumonia and clotting will not enhance proper activities if pain is not managed. Family encouragement and understanding of the rationale for completing these actions are important; however, pain control is the most helpful way to ensure ambulation, coughing, deep breathing, and turning can be performed. Text Reference - p. 358

When administering intravenous acetaminophen for acute pain, which drug considerations should the nurse be aware of? 1 The drug should be given over five minutes. 2 The daily dosage should not exceed 4 g/day. 3 The adjunct opioid dosage should be increased. 4 The nurse should monitor for renal toxicity.

2 Intravenous acetaminophen is used for the treatment of moderate to severe pain as an adjunct to opioid analgesics or as part of a multimodal analgesic regimen. The daily dosage of intravenous acetaminophen should not exceed 4 g/day, because it may cause liver toxicity. The drug is metabolized by the liver, and an overdose of more than 4 g/day or chronic use in patients with preexisting liver disease may lead to liver toxicity. The drug should be administered over 15 minutes. The adjunct opioid dosage should be decreased because acetaminophen has an opioid-sparing effect, allowing effective pain relief at lower opioid dosages. Acetaminophen does not have renal side effects. The nurse should be watchful for hepatotoxicity. Text Reference - p. 123

A patient with pancreatitis and on opioid therapy for pain relief informs the nurse of pain and difficulty in passing stools. A digital rectal examination (DRE) revealed fecal impaction. Which medication does the nurse determine to be beneficial for safe and effective care? 1 Modafinil 2 Methylnaltrexone 3 Dextroamphetamine 4 Transdermal scopolamine

2 Methylnaltrexone Pain and difficulty in passing stools is associated with constipation, which is a common side effect of opioid drugs. If left untreated, it leads to fecal impaction and paralytic ileus. Methylnaltrexone is a peripheral opioid receptor antagonist used for opioid-induced constipation when the patient does not receive relief from laxative therapy. Modafinil and dextroamphetamine are psychostimulants used for persistent sedation; they are usually used in opioid-naive patients being treated for acute pain. Transdermal scopolamine is an antiemetic used for nausea, which is often a problem for opioid-naïve patients. Text Reference - p. 126

The nurse finds that a postoperative patient has pulmonary edema (PE) characterized by low oxygen saturation and crackles on auscultation. Which is an appropriate nursing action? 1 Suction the airway. 2 Restrict fluid intake. 3 Monitor mental status. 4 Place the patient in lateral recovery position

2 Restrict fluid intake PE in a postoperative patient is due to fluid overload. Therefore, fluid restriction is the most appropriate intervention. In addition, oxygen therapy and diuretics can be administered. The airway is suctioned if there is any secretion retained in the system. Monitoring of mental status is done in the early postoperative period to determine emergence from anesthesia. Lateral recovery position is used in the early postoperative period to keep the airway patent and prevent aspiration in case the patient vomits. Text Reference - p. 352

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient? 1 Monitor pulse and blood pressure 2 Restoring circulating volume 3 An ECG to check circulatory status 4 Return to surgery to check for internal bleeding

2 The nurse should anticipate restoring circulating volume with intravenous (IV) infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration or there is a past history of cardiac disease or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if the patient's level of consciousness changes or the abdomen becomes firm and distended. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Text Reference - p. 355

Unless contraindicated by the surgical procedure, which position is safest for the unconscious patient immediately after the operation? 1 Supine 2 Lateral 3 Semi-Fowler's 4 High-Fowler's

2 Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient usually is returned to a supine position with the head of the bed elevated. Supine, semi-Fowler's, and high-Fowler's positions are all supine; they are not as helpful in keeping the airway open and reducing the risk of aspiration. Text Reference - p. 354

A patient prescribed transdermal fentanyl therapy reports a sudden increase in pain after 50 hours of drug administration. What should the nurse suspect is occurring with this patient? Select all that apply. 1 Breakthrough pain 2 Need to change dosage 3 Need for change in position 4 Neuropathic pain syndrome 5 Need to change the scheduling of the analgesic

2 Need to change dosage 5 Need to change the scheduling of the analgesic A sudden increase in pain after a period of drug administration is considered end-of-dose failure. This type of pain occurs before the expected duration of a specific analgesic and leads to a prolonged increase in the baseline persistent pain. This condition indicates the need for change in dose or scheduling of the analgesic for the prevention of harmful effects of acute pain. Breakthrough pain is transient and varies as being moderate to severe pain. Incident pain is a transient increase in pain due to a specific event or therapeutic procedure and indicates a need for a change in position. Neuropathic pain syndrome is caused by damage or injury to nerves and will not occur because of transdermal fentanyl therapy.

A patient who was on mechanical ventilation through an endotracheal tube develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube. How should the nurse manage this patient and ensure oxygenation? Select all that apply. 1 Suction the airway. 2 Administer oxygen therapy. 3 Administer muscle relaxants. 4 Provide positive pressure ventilation. 5 Tilt the head and thrust the jaw

2 Administer oxygen therapy. 3 Administer muscle relaxants. 4 Provide positive pressure ventilation Inspiratory stridor and sternal retraction are due to laryngospasm associated with removal of the endotracheal tube. Oxygen therapy helps maintain the perfusion levels in the patient. Skeletal muscle relaxants help relax the muscles and relieve laryngospasm. Positive pressure ventilation helps keep the patient oxygenated. Suctioning may increase laryngospasm. Tilting the head and thrusting the jaw does not help relieve laryngospasm. Text Reference - p. 352

A patient with a history of stroke is experiencing neuropathic pain with dramatic changes in skin color and warmth over the affected limb. What other findings should the nurse expect to assess in this patient? Select all that apply. 1 Allodynia 2 Intense burning pain 3 Increased urine retention 4 Increased skin sensitivity 5 Swelling of the affected limb

2 Intense burning pain 4 Increased skin sensitivity 5 Swelling of the affected limb Complex regional pain syndrome (CRPS) is a debilitating type of neuropathic pain characterized by changes in the color and temperature of the skin over the affected limb accompanied by intense burning pain, increased sensitivity of skin, sweating, and swelling. Allodynia is pain from stimuli which are not normally painful. Increased urine retention is a manifestation of acute pain. Text Reference - p. 119

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient? Select all that apply. 1 Ataxia 2 Itching 3 Nausea 4 Urinary retention 5 Gastrointestinal bleeding

2, 3, 4 Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine. Gastrointestinal bleeding is not a side effect of intraspinal opioids. Text Reference - p. 131

The nurse is monitoring a postoperative patient in the Phase I postanesthesia care unit (PACU). Discharge criteria for the Phase I patient include which of the following? Select all that apply. 1 No nausea or vomiting 2 No respiratory depression 3 Oxygen saturation above 90% 4 Written discharge instructions understood 5 Patient reports pain level of 4 on a 1 to 10 scale

2, 3, 5 Discharge criteria from Phase I are listed in Table 20-8 and include: oxygen saturation above 90%; no respiratory depression; and pain controlled or tolerable. Nausea and vomiting should be minimal. Understanding written discharge instructions are part of Phase II discharge criteria. Text Reference - p. 362

Which assessment is of highest priority for the nurse to complete before administration of morphine? 1 Pain rating 2 Blood pressure 3 Respiratory rate 4 Level of consciousness

3 A decreased respiratory rate below 12/minute is a sign of opioid toxicity. Using the airway, breathing, circulation (ABC) approach in prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine. Pain rating, blood pressure, and level of consciousness are all lower priorities for the nurse. Text Reference - p. 126

The nurse would report to the oncoming shift that acetaminophen administered to a patient was not effective after noting which parameter? 1 Productive cough with green sputum 2 Worsening dyspnea on exertion 3 Temperature 100.2° F 4 White blood cell count 11,000/mm3

3 Acetaminophen was prescribed to reduce fever caused by the pneumonia. The medication is not effective if the temperature remains elevated. Dyspnea, cough, and white blood cell count will not be impacted by administration of acetaminophen. Text Reference - p. 123

A nurse cares for a patient with acute pulmonary edema. Which assessment findings would the nurse expect to find? 1 Vertigo and headache 2 Palpitations and nausea 3 Anxiety and distended neck veins 4 Dry, hacking cough and chest pain

3 Anxiety and distended neck veins The patient experiencing acute pulmonary edema would most likely experience anxiety related to hypoxia. Distended neck veins would be present because of decreased cardiac output resulting in right-sided heart congestion, causing blood to back up into the neck veins. Vertigo and headaches, and palpitations and nausea may be present but are not as distinct and common as anxiety, distended neck veins, and shortness of breath. The cough associated with pulmonary edema will be moist and productive. In severe cases, this may present as pink and frothy sputum. Chest pain may also be present. Text Reference - p. 352

What should the nurse consider when managing severe pain due to fracture of a thigh bone in a patient with a history of opioid abuse? 1 A mixed opioid agonist-antagonist agent is preferred over single opioid. 2 Nondrug pain relief measures are ineffective and should not be used. 3 The opioid should be given at higher dosages than in drug-naive patients. 4 Opioids should be administered only when the patient experiences severe pain.

3 In a patient with a history of opioid use, severe pain is treated with opioids at much higher dosages than in drug-naive patients. The use of a single opioid is preferred. Using a mixed opioid agonist-antagonist such as butorphanol or a partial agonist such as buprenorphine should be avoided because these drugs may precipitate withdrawal symptoms. Nondrug pain relief measures may also be used as appropriate. The nurse should not wait for the pain to become severe to administer the drug. The analgesic should be provided around the clock to maintain opioid blood levels and prevent withdrawal symptoms. Text Reference - p. 137

The nurse is caring for a patient receiving morphine sulfate 10 mg intravenous (IV) push as needed for pain. Upon assessment, the nurse finds the patient semiconscious with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms? 1 Atropine sulfate 2 Protamine sulfate 3 Naloxone 4 Neostigmine bromide

3 Naloxone is the antidote or reversal agent for opioid analgesics, such as morphine. Excessive sedation and respiratory depression are symptoms of overdose or severe adverse effects that must be reversed for patient safety. Text Reference - p. 126

A nurse educator is conducting a class on pain for nursing students. The nurse educator explains nociception. Which description given by the nurse educator is most appropriate for nociception? 1 "It is the process of conversion of a noxious stimulus into action potential." 2 "It is the process of relaying pain information from the peripheries to the spinal cord." 3 "It is the process of communicating information about tissue damage to the central nervous system." 4 "It is the process occurring in pain pathways that causes facilitation or inhibition of pain perception."

3 Nociception is a broad term that involves many smaller processes, and includes transduction, transmission, perception, and modulation. Nociception is the physiologic process of communicating information about tissue damage, from the area of damage to the central nervous system. The process of conversion of a noxious stimulus into action potential is called transduction, and is the first stage in the process of nociception. The process of relaying information from the peripheries to the spinal cord is called transmission. Processes causing facilitation or inhibition of pain are referred to as pain modulation. Text Reference - p. 118

A patient with diabetes is experiencing extreme pain on the bottom of both feet. What type of pain should the nurse suspect that the patient is experiencing? 1 Central pain 2 Deafferentation pain 3 Peripheral neuropathy 4 Sympathetically maintained pain

3 Peripheral neuropathy Foot pain is a type of peripheral neuropathy. Central pain is a type of neuropathic pain caused by damage of or dysfunction in the central nervous system. Poststroke pain is an example of central pain. Deafferentation pain (such as phantom limb pain) is a type of neuropathic pain, which results from loss of afferent input. Sympathetically maintained pain is a type of neuropathic pain that persists secondary to sympathetic system activity. Complex regional pain syndrome is an example of this type. Text Reference - p. 118

A nurse is caring for a patient, who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. What action should the nurse take? 1 Encourage oral (PO) fluids 2 Continue to monitor the urine output 3 Notify the primary health care provider 4 Administer a 500 cc normal saline intravenous (IV) bolus

3 The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours. It often takes three to five days for the bowel to begin working postabdominal surgery; therefore, it would be inappropriate at this time to encourage PO fluids. Continuing to monitor the urine output, instead of calling the primary health care provider, would delay identifying and treating the cause for the low urine output. The nurse must obtain a prescription for the normal saline bolus before administration. Text Reference - p. 360

An asthmatic patient develops wheezing on the postoperative unit. The nurse finds that the patient is tachypneic, has dyspnea, and has reduced oxygen saturation. How will the nurse prevent further pulmonary complications? 1 Provide incentive spirometry. 2 Encourage chest physical therapy. 3 Administer bronchodilators. 4 Provide nebulization of histamine vapors

3 The presence of wheeze, tachypnea, and reduced oxygen saturation indicates bronchospasm. The use of bronchodilators relieves bronchospasm and promotes a patent airway. Incentive spirometry is useful in managing atelectasis when the airway is patent. Chest physical therapy is helpful to clear secretions from the respiratory tract. Histamine vapors aggravate bronchospasm, and therefore should be avoided. Text Reference - p. 352

The patient with pneumonia has a temperature of 101º F. There is a prescription to administer ibuprofen 600 mg by mouth (PO) for a temperature greater than 100º F. Available are 200-mg tablets. How many tablets should the nurse administer? 1 One tablet 2 Two tablets 3 Three tablets 4 Four tablets

3 Using ratio and proportion, multiply 200 by x and multiply 600 × 1 to yield 200x = 600. Divide 600 by 200 to yield three tablets. Text Reference - p. 123

A patient with a history of venous thrombosis had major abdominal surgery. Which nursing interventions are helpful in preventing the development of venous thrombosis? Select all that apply. 1 Use of diuretics 2 Delayed ambulation 3 Use of dalteparin 4 Corticosteroids 5 Sequential compression devices

3 Use of dalteparin 5 Sequential compression devices Dalteparin is an anticoagulant that may be used as prophylactic agent to prevent development of venous thrombosis. Sequential compression devices also help prevent development of venous thrombosis by promoting venous return. Diuretics help remove excess fluid from the body, however, they do not help prevent thromboembolism. Corticosteroids suppress the immune response but have no effect on blood clotting. Late ambulation is a risk factor for venous thrombosis.

A patient on the postoperative unit develops an airway obstruction due to the tongue falling back. How should the nurse ensure a patent airway? Select all that apply. 1 By suctioning the airway 2 By administering oxygen therapy 3 By tilting the head and thrusting the jaw 4 By administering sedatives 5 By putting in an artificial airway

3, 5 The physical repositioning of a patient to reestablish the patency of the airway involves tilting the head and thrusting the jaw. If the physical repositioning does not help, the patient may need an artificial airway to assist in breathing. Suctioning is helpful for patients with increased secretions; it may not help a patient with an airway obstruction. Oxygen therapy does not help unless the airway is patent. Sedatives would worsen the airway prolapse. Text Reference - p. 352

The nurse should instruct a patient receiving nonsteroidal antiinflammatory drugs (NSAIDs) to report which effect? 1 Blurred vision 2 Nasal stuffiness 3 Urinary retention 4 Black or tarry stools

4 Black, tarry stools could indicate gastrointestinal (GI) bleeding, which is a risk associated with NSAIDs. For this reason, the patient should be taught to report this sign and other signs of bleeding immediately. Blurred vision, nasal stuffiness, and urinary retention are not effects that need to be reported to the nurse. Text Reference - p. 123

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? 1 Check the chart for intraoperative complications. 2 Check which medications were used for anesthesia. 3 Check the effectiveness of the analgesics received. 4 Check the preoperative assessment for previous delirium or dementia

4 Check the preoperative assessment for previous delirium or dementia. If the patient's airway, breathing, and circulation are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed, because these can all contribute to delirium. Text Reference - p. 357

An alcoholic patient who has undergone a hernia operation is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? 1 Conclude that the patient suffers from a psychotic disorder. 2 Consider the situation normal, due to the anesthetic drugs. 3 Infer that the patient is suffering from pain and suggest using pain killers. 4 Conclude that these effects are due to alcohol withdrawal

4 Conclude that these effects are due to alcohol withdrawal The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient does not have a history of psychotic illness; therefore, the symptoms cannot be attributed to a psychotic disorder. Anesthetic drugs may cause delirium, but not hallucinations. Pain may cause restlessness and irritability, but not hallucinations. Text Reference - p. 357

During physical examination, the nurse finds that the patient with sunburn on the face experiences pain on touch. Which of these may be the reason for pain in the sunburned area? 1 Referred pain 2 Neuroplasticity 3 Windup process 4 Peripheral sensitization

4 Peripheral sensitization Sunburn is a thermal injury and may cause inflammation. The inflammation may result in a sensation of pain when the affected skin is lightly touched. This is called peripheral sensitization, and it is facilitated by cyclooxygenase (COX), an enzyme produced in the inflammatory response. The enzyme increases susceptibility to nociceptor activation in response to nonnoxious stimuli. When the location of a stimulus is distant from the pain location reported by the patient, the pain is called referred pain. Neuroplasticity refers to processes that allow neurons in the brain to compensate for injury and adjust their responses to new situations or changes in the environment. Windup refers to the capacity of neurons to transmit a broader range of stimuli-producing signals, which are then passed up the spinal cord and brain. Windup depends on activation of N-methyl-d-aspartate (NMDA) receptors. Text Reference - p. 116

A postoperative patient has decreased breath sounds and decreased oxygen saturation. The nurse understands that the anesthetic agents may stimulate bronchial secretion. On auscultation the nurse finds an absence of breath sounds on one lung. What interventions should be included in the postoperative care to maintain adequate oxygen saturation? Select all that apply. 1 Administer diuretics. 2 Allow delayed ambulation. 3 Instruct shallow breathing. 4 Encourage incentive spirometry. 5 Provide humidified oxygen therapy.

4 Encourage incentive spirometry. 5 Provide humidified oxygen therapy. Decreased breath sounds and a low oxygen saturation level may indicate atelectasis due to retained secretions. Incentive spirometry helps lung expansion and promotes removal of secretions. Humidified oxygen therapy helps maintain the oxygen saturation levels. Diuretics help remove excess fluid in the body, but do not help in atelectasis. Late ambulation and shallow breathing aggravate atelectasis; therefore, the patient should be mobilized early and deep breathing should be encouraged. Text Reference - p. 352

A patient is having elective cosmetic surgery performed on the face. The patient will remain at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? 1 Manage patient pain 2 Control the bleeding 3 Maintain fluid balance 4 Manage oxygenation status

4 Manage oxygenation status The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise the patient's ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase the risk for upper airway edema, causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

The nurse administering a dose of oxycodone with acetaminophen would ensure the patient does not have a history of allergy to which substance? 1 Acetaminophen 2 Meperidine 3 Aspirin 4 Oxybutynin

Acetaminophen Acetaminophen is one of the active ingredients in Percocet, and therefore the nurse should be certain the patient does not have an allergy to acetaminophen before administering the medication. Percocet does not contain meperidine, Demerol, aspirin, or oxybutynin; therefore, there is no risk of associated allergy. Text Reference - p. 125

In teaching a postcoronary bypass patient about the risk of venous thromboembolism (VTE), it is important to stress: 1 Early ambulation 2 Turning every 2 hours 3 Splinting chest while coughing 4 Importance of taking pain medication

Activity has proven vital in helping to prevent postoperative VTEs. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every 2 hours are important for the recovery of the coronary bypass patient, but have little impact on preventing VTE. Text Reference - p. 356

A patient is hospitalized with multiple lacerations and four fractured ribs after a fall. The nurse, creating a plan of care, recognizes that which action is the highest priority? 1 Providing a high-protein, high-calcium diet 2 Performing range-of-motion exercises during morning care 3 Administering analgesics and encourage breathing exercises 4 Keeping the patient NPO and performing oral hygiene at least every four hours

Administering analgesics and encourage breathing exercises Administering analgesics is the highest priority action to achieve patient comfort, and thereby facilitate performance of breathing exercises to prevent respiratory complications such as atelectasis and pneumonia. A high-protein, high-calcium diet will assist with wound and fracture healing. Range-of-motion exercises may be performed after the patient is medicated for pain. The patient does not need to be on nothing-by-mouth status unless there is a specific reason. Text Reference - p. 120

A patient is receiving morphine therapy for the treatment of pain related to cancer treatment. What nursing action is the most beneficial for this patient, who is having the side effect of constipation? 1 Advising the patient to use a stool softener 2 Decreasing the dose of the morphine by 10 percent to 15 percent 3 Changing to a different medication in the same class 4 Administering the drug through another administration route

Advising the patient to use a stool softener Morphine is an opioid that helps reduce pain perception, but it has side effects, such as constipation. Therefore, advising the patient to start using a stool softener for constipation is the most beneficial intervention. The primary health care provider should decrease the dose of drug by 10 percent to 15 percent if the patient is experiencing overdose effects. The primary health care provider should change drugs or switch to a different medication in the same class if the patient is not showing a decrease in symptoms after drug use. The primary health care provider should change the route of drug administration if the patient is experiencing side effects related to the present route of administration. Text Reference - p. 123

A patient in pain is anxious, fearful, and angry. Which pain dimension is this patient demonstrating? 1 Affective 2 Cognitive 3 Behavioral 4 Physiologic

Affective The biopsychosocial model of pain includes five dimensions of pain: physiologic, affective, cognitive, behavioral, and sociocultural. The affective dimension involves emotional responses to pain including anger, anxiety, fear, and depression. The cognitive dimension involves beliefs, attitudes, memories, and meaning attributed to the pain. The behavioral dimension involves the use of observable actions such as grimacing and irritability to express or control pain. The physiologic dimension involves genetic, anatomic, and physical determinants of pain. Text Reference - p. 115

A patient who is still drowsy and recovering from anesthesia has been vomiting. How can the nurse prevent aspiration in this patient? 1 Avoid using suctioning devices. 2 Position the patient in prone position. 3 Position the patient in supine position. 4 Place the patient in lateral recovery position.

Aspiration of the vomitus can be prevented by placing the patient in the lateral recovery position. This position helps the vomitus escape through the mouth. A suctioning device may be used to remove the vomitus to prevent aspiration. Supine and prone positions are less helpful in preventing aspiration than the lateral recovery position. Text Reference - p. 360

A patient requires treatment with an analgesic, antipyretic, and antiinflammatory. Which nonopioid medication administered by the nurse would be of most benefit to the patient? 1 Aspirin 2 Ibuprofen 3 Diclofenac K 4 Acetaminophen

Aspirin Aspirin is a salicylate drug of the nonopioid category. It is used as an analgesic for mild pain, an antipyretic, and an antiinflammatory drug. Ibuprofen and diclofenac K are nonsteroidal antiinflammatory drugs (NSAIDs). Ibuprofen is an analgesic used for the treatment of pain for only a short duration due to its side effects. Diclofenac is an analgesic that is well-tolerated and is not used as an antipyretic or antiinflammatory drug. Acetaminophen is a nonsalicylate drug used as an analgesic and antipyretic but it is not an antiinflammatory drug. Text Reference - p. 123

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? 1 Assess the patient's pain 2 Assess the patient's vital signs 3 Check the rate of the intravenous (IV) infusion 4 Check the health care provider's postoperative prescriptions

Assess the patient's vital signs The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. Assessing the patient's pain, checking the rate of the IV infusion, and checking the health care provider's postoperative prescriptions then can take place in rapid sequence. Text Reference - p. 352

A postoperative patient develops fever, abdominal pain, and diarrhea despite being on long-term antibiotics. What should the nurse evaluate for? 1 Wound infection 2 Urinary infection 3 Respiratory infection 4 Clostridium difficile infection

Clostridium difficile infection Prolonged use of antibiotics increases the risk of Clostridium difficile infection by damaging the normal flora of the intestine. The infection is manifested as fever, diarrhea, and abdominal pain. Wound infection, urinary infection, and respiratory infection may present with fever, but these infections rarely present with diarrhea and abdominal pain. Text Reference - p. 359

The nurse is reviewing the definition of pain. Which of these are correct when defining pain? Select all that apply. 1 Pain is a subjective experience. 2 Pain is a creation of a person's imagination. 3 Pain is a maladaptive response to a stimulus. 4 Pain is an unpleasant sensory and emotional experience. 5 Pain is an experience associated with actual or potential tissue damage.

Correct1 Pain is a subjective experience. Correct4 Pain is an unpleasant sensory and emotional experience. Correct5 Pain is an experience associated with actual or potential tissue damage. The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Pain is a subjective measure, in which the patient's self-report is the most valid means of assessment. Pain is not imaginary or a poor response to a stimulus. Text Reference - p. 115

An elderly postoperative patient has difficulty with memory and the ability to concentrate. What should the nurse do to help this patient? Select all that apply. 1 Encourage delayed mobility. 2 Provide bowel and bladder care. 3 Provide adequate nutrition. 4 Sedate the patient for long durations. 5 Monitor fluid and electrolyte disturbance.

Correct2 Provide bowel and bladder care. Correct3 Provide adequate nutrition Correct5 Monitor fluid and electrolyte disturbance. The patient suffers from postoperative cognitive dysfunction, which dissipates over a few weeks. The nurse should provide supportive care during this period, such as bowel and bladder care, adequate nutrition, and fluid and electrolyte monitoring. Early mobilization should be encouraged to prevent pulmonary complications. Sedatives should not be used, because they further add to cognitive dysfunction. Text Reference - p. 357

The nurse questions a prescription for celecoxib upon identification of which assessment finding? 1 Migraine headache 2 Dark stools 3 Blood pressure 108/58 mm Hg 4 Hypoactive bowel sounds

Dark stools Celecoxib can increase the risk of gastrointestinal bleeding. The nurse should question the prescription if the patient is having dark stools, which may worsen preexisting bleeding. Migraine headache may be treated with celecoxib. This medication will have no effect on blood pressure or bowel sounds. Text Reference - p. 123

A nurse is teaching a group of patients about the use of heat therapy for relief of arthritis pain. Which of these is a correct statement about heat therapy? 1 Apply directly on areas that have decreased sensation. 2 Do not use menthol-containing products with heat applications. 3 Do not cover the heat source with a towel or cloth before applying. 4 Heat therapy is more effective than cold therapy in relieving pain.

Do not use menthol-containing products with heat applications. Menthol-containing products (such as Vicks) should not be used with heat applications because they may cause burns. The heat should not be directly applied to areas with decreased sensation because it may lead to tissue damage. The heat source should be covered with a towel or cloth before applying to the skin to prevent burns. In general, heat therapy is less effective than cold for a variety of painful conditions, including arthritis. Text Reference - p. 132

A patient on the postoperative unit has shallow respirations. On examination, the nurse finds the patient to be hypoxemic. After inquiry, it was discovered that the patient was given a large dose of opioids during the surgery. What would the nurse expect to be prescribed to manage hypoxemia in this patient? 1 Opioids 2 Benzodiazepines 3 Drugs to reverse the effects of opioids 4 Withholding mechanical ventilation

Drugs to reverse the effects of opioids Shallow respiration associated with hypoxemia and reduced respiratory rate in a patient who received large doses of opioids indicates hypoventilation due to medullary depression. Drugs that reverse the effect of opioids should be administered to stimulate the medullary respiratory center. Opioids and benzodiazepines should be avoided because they further aggravate medullary depression. In severe medullary depression, the patient may need mechanical ventilation. Text Reference - p. 352

A nurse is providing postoperative care for a patient who has undergone exploratory abdominal surgery. To prevent the complication of atelectasis, what interventions should the nurse perform? 1 Medicating the patient with a narcotic analgesic as prescribed 2 Providing an abdominal binder to help the patient in ambulation 3 Encouraging the use of an incentive spirometer at least every hour 4 Turning the patient from one side to the other at least every 2 to 4 hours

Encouraging the use of an incentive spirometer at least every hour Use of an incentive spirometer after surgery encourages the patient to take deep, slow breaths, which facilitates the opening of terminal airways, mobilizes secretions, and prevents postoperative atelectasis. Narcotic analgesics, use of an abdominal binder for ambulation, and frequent turning in bed may indirectly support recovery and prevention of complications postoperatively. However, these interventions do not specifically address prevention of atelectasis and pneumonia in the way that the use of an incentive spirometer does. Text Reference - p. 354

Which nursing interventions, according to the Pasero Opioid-Induced Sedation Scale (POSS) with Interventions, are beneficial to the patient who is drowsy and drifts to sleep during conversation following opioid therapy? Select all that apply. Decreasing opioid dose 25% to 50% Initiating naloxone therapy for the patient Documenting the condition as acceptable to therapy Administering opioid-sparing nonopioid to the patient Monitoring the patient's respiratory status continuously

Frequent drowsiness and drifting off to sleep during conversation indicates that the patient is at level 3 of sedation according to the Pasero Opioid-Induced Sedation Scale (POSS). The appropriate nursing interventions at level 3 sedation are reducing the opioid dose 25% to 50% to decrease sedation, administering an opioid-sparing nonopioid such as acetaminophen or an NSAID along with the opioid, and monitoring the patient's respiratory status continuously until the sedation level is stable. Patients who are at level 4 sedation are somnolent and do not respond to verbal or physical stimulation. Naloxone is an opioid antagonist and is administered to the patient at level 4 sedation. Opioid-induced level 3 sedation is unacceptable due to the risk of life-threatening complications. Test-Taking Tip: Opioids are analgesics, which provide pain relief but should be limited with appropriate interventions to prevent side effects. Text Reference - p. 127

In postanesthesia care unit (PACU), a patient's blood pressure drops from 110/60 mm HG to 92/58 mm Hg. What actions should the nurse take? Select all that apply. 1 Assess ECG tracing 2 Inspect the surgical site 3 Administer pain medication 4 Have the patient take deep breaths 5 Administer intravenous (IV) fluid bolus per protocol 6 Administer prescribed metoprolol

Have the patient take deep breaths; hypoxemia can cause hypotension. Hypotension in the postoperative patient can be due to various reasons, but the nurse should begin by treating hypoxemia. Inspect the surgical site; hypotension can be caused by hemorrhage. Therefore, it is important to inspect the surgical site for evidence of bleeding. Administer IV fluid boluses per protocol; fluid shifts during and after surgery can cause a drop in blood pressure. Fluid boluses often are needed to correct for these shifts. Assess ECG tracing; a change in the heart rhythm can cause a decrease in blood pressure. Some of these rhythms include supraventricular tachycardia, sinus bradycardia, atrial fibrillation, and atrial flutter. Hypertension, not hypotension, is indicative of pain. A side effect of many pain medications is hypotension, which would exacerbate the patient's present hypotensive state. Metoprolol causes a decrease in blood pressure. If the patient is hypotensive, the prudent nurse should hold the metoprolol and notify the primary health care provider. Text Reference - p. 355

Which nursing intervention is important to prevent syncope in a postoperative patient? Administer oxygen therapy Administer analgesics before ambulation Make changes in the patient's position slowly Encourage deep breathing and coughing exercises.

Make changes in the patient's position slowly To prevent syncope in a postoperative patient, the nurse should slowly change the patient's position. Progression to ambulation can be achieved by first raising the head of the patient's bed for 1 to 2 minutes and then assisting the patient to sit, with legs dangling, while monitoring the pulse rate. If no changes or complaints are noted, start ambulation with ongoing monitoring of the pulse. Oxygen therapy and deep breathing and coughing exercises are interventions to improve pulmonary function, not to prevent syncope. Administering analgesics before ambulation makes the activity painless and encourages the patient to become more active. Text Reference - p. 357

A patient admitted with metastatic lung cancer is prescribed morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication? 1 Diarrhea 2 Agitation 3 Constipation 4 Urinary incontinence

Morphine sulfate is an opioid analgesic that can lead to constipation as a side effect, and tolerance to opioid-induced constipation does not develop. It is very important to use measures, such as increased fiber and fluids in the diet, and exercise when possible, to prevent this side effect. A gentle stimulant laxative plus a stool softener also are frequently needed to prevent constipation in a patient who is likely to develop this side effect. Text Reference - p. 126

Which clinical manifestation should the nurse attribute to adverse effects of morphine sulfate administered via patient-controlled analgesia (PCA)? 1 Diarrhea 2 Urinary incontinence 3 Nausea and vomiting 4 Increased blood pressure

Nausea and vomiting Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, decreased blood pressure, and pruritus. Text Reference - p. 126

A patient, who is eight hours postappendectomy, has not voided since surgery. What action should the nurse take? 1 Encourage oral (PO) fluid intake 2 Insert an in and out catheter to assess for retention 3 Palpate the suprapubic area for bladder distention 4 Check the medical record to determine the type of anesthetic given

Palpate the suprapubic area for bladder distention The nurse needs to know first if there is urine in the bladder. The assessment can be done by palpating or scanning the suprapubic area. Encouraging PO fluid intake is appropriate if the patient can tolerate PO fluids and there is no bladder distention. Because of the risk of infection, an in and out catheter is not used for assessment purposes but to relieve known urine retention. No matter what type of anesthetic was administered, the nurse needs to determine if the patient has not voided because of a lack of urine output or if the issue is an alteration in micturition. Text Reference - p. 360

The nurse caring for a postoperative patient assesses clinical manifestations of early pulmonary edema. What manifestations does the nurse determine correlates with this disorder? 1 Early-morning cough 2 Increased urine output 3 Paroxysmal nocturnal dyspnea 4 Crackles heard on auscultation

Paroxysmal nocturnal dyspnea The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. Between the two, shortness of breath in the form of paroxysmal nocturnal dyspnea is the earlier symptom, although crackles is more common. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Crackles heard on auscultation of the lungs is one of the more common symptoms of pulmonary edema, along with coughing of frothy pink-tinged sputum.

After administering acetaminophen and oxycodone for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? 1 Leave the overbed light on a low setting. 2 Ensure that the upper two side rails are raised. 3 Offer to turn on the television to provide distraction. 4 Ensure that documentation of intake and output is accurate.

Percocet has acetaminophen and oxycodone as ingredients. Because the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the top two bed rails raised. This will help prevent the patient from falling from bed, while not restraining the patient (as four side rails would do). Leaving the light or television on will not provide a positive environment for healing sleep. Text Reference - p. 126

Which statement about referred pain is correct? 1 The pain arises from skin and mucous membranes. 2 Referred pain includes painful responses to normally innocuous stimuli. 3 Referred pain is prolonged pain after the original noxious stimuli ends. 4 Referred pain is pain perceived at a location other than the site of noxious stimuli.

Referred pain is pain perceived at a location other than the site of noxious stimuli Referred pain is described as location of pain distant from the location of a stimulus. During pain assessment, the nurse assesses the referred pain in order to locate the pain. If the pain is arising from the skin and mucus membranes, then it is considered as superficial somatic pain, but not referred pain. Allodynia is described as the production of painful responses to normally innocuous stimuli. Persistent pain is described as pain lasting for longer periods after the original noxious stimuli ends. Text Reference - p. 121

The nurse monitoring the respiratory status of a patient receiving morphine sulfate by the intravenous (IV) route for pain would immediately notify the health care provider if which assessment finding were noted? 1 Pupillary constriction 2 Respiratory rate 8 breaths/minute 3 Blood pressure 160/96 mm Hg 4 Hypoactive bowel sounds

Respiratory rate 8 breaths/minute The nurse should notify the health care provider that the patient is experiencing respiratory depression from morphine sulfate if the respiratory rate drops below 12 breaths/minute. Pupillary constriction and decreased blood pressure are expected effects of morphine administration. Constipation may occur normally, which may result in hypoactive bowel sounds and would not be an emergency situation. Text Reference - p. 124

While caring for a patient after a colectomy on the first postoperative day, the nurse notes new bright-red drainage about 4 cm in diameter on the surgical dressing. What is the priority nursing action? 1 Take the patient's vital signs. 2 Mark the area on the dressing and document the finding. 3 Recheck the dressing in one hour for increased drainage. 4 Notify the health care provider of a potential hemorrhage

Take the patient's vital signs The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report the findings to the provider. Marking the area is acceptable, but not the priority nursing action. Rechecking the dressing in an hour increases the risk of adverse outcomes by waiting more time to notify the health care provider about a potential bleeding complication. The health care provider should be notified after the nurse assesses the patient. Text Reference - p. 361

What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy? 1 Assess the patient's pain. 2 Take the patient's vital signs. 3 Check the rate of the intravenous (IV) infusion. 4 Check the health care provider's postoperative prescriptions.

Take the patient's vital signs. highest priority

A patient is being discharged after laparoscopic cholecystectomy. The nurse should instruct the patient to notify the surgeon immediately if which condition develops? 1 Constipation 2 Right shoulder pain 3 Decreased appetite 4 Temperature of 103° F

Temperature of 103° F The primary health care provider should be notified immediately if the patient experiences an increase in temperature higher than 101° F because this may be indicative of an infectious process that will require immediate interventions to resolve. Right shoulder pain is expected after a laparoscopic surgery and is resolved within 48 to 72 hours. Constipation and decreased appetite may occur. If these do not resolve after discharge, the patient should be instructed to contact the primary health care provider. Text Reference - p. 359

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure of 100/60 mm Hg. Which action should the nurse take first? 1 Rouse the patient 2 Place the patient in the Trendelenburg position 3 Notify the anesthesiologist of the low blood pressure Correct 4 Check the medical record for the patient's baseline blood pressure

The first action of the nurse is to identify what the patient's normal blood pressure is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the blood pressure, but would be done after determining the baseline blood pressure. Placing the patient in Trendelenburg is not an appropriate action in this situation. Before notifying the anesthesiologist of the blood pressure, the nurse needs to check the baseline blood pressure. Text Reference - p. 355

A nurse is caring for an 82-year-old patient, who had a knee replacement the previous day. The patient denies any pain. Which response by the nurse would be most appropriate? 1 "Excellent. You must be able to handle a lot of pain." 2 "Great. It is wise to only take the pain medication if you need it." 3 "It is important that you take pain medication. It will help you recover quicker." 4 "Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"

Thoroughly assessing the presence of pain is imperative, especially for those who deny any pain after surgery, especially the elderly. Gerontology patients may hesitate reporting pain because of the belief that pain should be tolerated and is inevitable postsurgery. It is not appropriate to compliment the patient on being able to handle pain. The patient will not develop an addiction to pain medication, so it is not appropriate to tell the patient he or she should only take it when necessary. The nurse should not tell the patient that pain medication will help him or her recover quicker, because that could give the patient false reassurance. Text Reference - p. 368

It is time for a patient's scheduled dose of celecoxib 200 mg by mouth (PO). Available are capsules containing 100 mg. How many capsules should the nurse administer? 1 0.5 capsule 2 2 capsules 3 5 capsules 4 10 capsules

Using ratio and proportion, multiply 100 by x and multiply 200 × 1 to yield 100x = 200. Divide 200 by 100 to yield 2 capsules. Test-Taking Tip: Start with answering all the questions that you feel confident in answering. If you cannot immediately think of the answer to a question, give it a few seconds of thought. If the answer comes to you, mark it and move on. If not, skip it, circle the number so you know to come back to it, and go to the next question. Text Reference - p. 123

When administering an analgesic to a postoperative patient, which nursing actions should the nurse take? Select all that apply.

When administering an analgesic to a postoperative patient, which nursing actions should the nurse take? Select all that apply. Correct1 Assess the location, quality, and intensity of pain. 2 Assess the patient's sleep/wake cycle and sensory and motor status. Correct3 Time the analgesic administration for effectiveness during painful activities. 4 Assess the patient's level of orientation and ability to follow commands. Correct5 Monitor the patient for nausea, vomiting, and respiratory depression. When administering analgesics to a postoperative patient, the nurse should assess the location, quality, and intensity of pain. The time of administration of the analgesic should be adjusted so that the patient is free of pain during activities like ambulation. The nurse should monitor the patient for analgesic side effects, including nausea, vomiting, and respiratory depression. Assessing the sleep/wake cycle, sensory and motor status, level of orientation, and ability to follow instructions are part of a neurologic assessment and not a part of administering an analgesic. Text Reference - p. 358

The nurse is teaching deep breathing and coughing techniques to a postoperative patient with an abdominal incision. Which important instruction should the nurse include in her teaching regarding safe use of this technique? 1 Splint the abdominal incision with a pillow. 2 Perform the technique two times every waking hour. 3 Encourage deep breathing and coughing if the patient is in pain or feels the urge to clear secretions. 4 Limit fluid intake to thicken the secretions and membranes.

When performing deep breathing and coughing exercises, the patient should splint the abdominal incision site with a pillow or folded blankets to support the incision. The patient may be instructed to perform the technique 10 times every hour if the condition allows. The nurse should assure the patient that the breathing and coughing techniques will not harm the incision site and are essential to mobilizing secretions. The patient should be instructed to drink sufficient water to keep the secretions thin. Text Reference - p. 354

A patient has been diagnosed with Addison's disease and reports severe back and abdominal pain. The nurse finds increased level of adrenocorticotropic hormone (ACTH) in the lab results. Which clinical manifestation is the nurse most likely to find in the patient? 1 Pallor 2 Cyanosis 3 weight loss 4 Dehydration

weight loss Unrelieved pain can affect the endocrine system and cause an increase in the levels of adrenocorticotropic hormone (ACTH). Elevated ACTH levels result in increased catabolic processes in the body. This ultimately causes weight loss. Pallor, cyanosis, and dehydration do not indicate presence of pain in the patient. Pallor, paleness of the skin, is caused by anemia. Cyanosis is the bluish discoloration of the skin and the mucous membrane that is associated with tissue hypoxia. Dehydration is not associated with increased ACTH levels. Text Reference - p. 117