A&C I Practice Pain Assessment #1

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

Self-report of pain According to evidence-based practice, the most reliable indicator of pain is the client's self-report of pain. A pain intensity scale is a reliable too to identify the client's pain level.

A nurse is caring for a client who had a total hip arthorplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Auscultate bowel sounds Using the nursing process, assessing for the presence or absence of bowel sounds and the passage of flatus is an appropriate action at this time. Determining the cause of the nausea and reducing contributing factors should precede any treatment.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10 Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.

A nurse is teaching a client who has a new prescription for codeine. Which of the following instructions should the nurse include in the teaching

"You should change positions slowly." The client should change positions slowly to avoid the risk of falls. Codeine is an opioid analgesic that causes CNS depression and orthostatic hypotension.

The nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose?

3 Capsules

A nurse is caring for a client receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions hsould the nurse take first?

Check the display o the PCA pump The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should assess the display on the PCA pump to determine the amount of medication administered. Some clients are fearful of developing an addiction to narcotics and may be reluctant to use the PCA.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.

A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?

Euphoria Euphoria is an adverse effect of opioid analgesics and is due to activation of mu receptors.

A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take?

Have another nurse witness the disposal of the extra medication. Any excess narcotic must be disposed. The disposal must be witnessed and documented by a second nurse.

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority

Respiratory rate When using the airway, breathing, circulation approach to client care, the nurse should determine the priority assessment is respiratory rate. Morphine can cause respiratory depression. The nurse should withhold the medication and notify the prescriber if the client has a respiratory rate less than 12/ mins.

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

TENS units are portable. The client can use his TENS unit at home or whenever he chooses.

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?

Take medication with food To minimize gastric irritation, the client should take ibuprofen with food or immediately after a meal.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain

The client's self-report of pain severity Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly.

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first.

Discontinue the existing IV line The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line.

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

Increased HR Acute pain stimulates the sympathetic nervous system and can cause an increase in heart rate.

The nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a Patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an understanding of the teaching?

"I should tell the nurse if I can't control my pain with this device." PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self-administer pain medication on an as-needed basis The client should notify the nurse if pain control is not achieved. The nurse can initiate a re-evaluation of the client's pain management plan.

A nurse is caring for a client who is using a PCA pump for postioperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

"Your husband should decide when more medication is needed." The nurse should explain to the client's partner that the client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.

A nurse is planning care for a client who is postoperative. Which if the following statements about pain management should the nurse consider when implementing client care?

Each client's expression of pain may be different and individualized. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. Pain level and pain tolerance can be assessed using a scale from 0 to 10.

A nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. The nurse should instruct the client to monitor for which of the following adverse reactions to this medication?

Jaundice Acetaminophen can cause hepatotoxicity. The client should monitor and report jaundice, abdominal pain, clay colored stools, and fever.

A nurse is planning to administer butorphanol to a client who is in labor. Which of the following medications should the nurse plan to have available to reverse the action of this medication?

Naloxone Butorphanol is an opioid analgesic. The nurse should have the opioid reversal agent naloxone and resuscitation equipment available in the event that the client develops respiratory depression.

A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer?

Naloxone The nurse should plan to administer naloxone, which is an opiate antagonist that competes with opioids at opiate receptor sites making the opioid ineffective

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

The client developed a tolerance to the medication The nurse should document that the client has developed a tolerance to the medication. Morphine is a narcotic analgesic used for the treatment of severe pain. Tolerance is an adverse effect of narcotic analgesics in which a larger dose is needed to produce the same response.

A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

Tinnitus The nurse should identify tinnitus, or ringing in the ears, as an adverse effect of aspirin that indicates salicylism.

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

Orthostatic hypotension The nurse should monitor the client for orthostatic hypotension and encourage the client to rise or change position slowly to decrease the risk for falls.