Med-surg Ch 5 & 9 questions

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, which statement or question by the nurse is most appropriate? a. "Help me understand how pain is affecting you right now." b. "I wish I could do more; is there anything I can get for you?" c. "You cannot have more pain medication for 3 hours." d. "Why do you think the medication is not helping your pain?"

ANS: A A client who is preoccupied with physical symptoms and is "demanding" may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client's situation. "Why" questions are probing and often make clients defensive, plus the client may not have an answer for this question.

A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? a. "Being able to sleep doesn't mean pain doesn't exist." b. "Have you ever experienced any type of pain?" c. "The client should be assessed for drug addiction." d. "You're right; I would put the medication back."

ANS: A A client's description is the most accurate assessment of pain. The nurse would believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them would not supersede the client's descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client's report of pain serves no useful purpose and is unethical.

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

ANS: A Anxiety can interfere with learning, coping, and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.

ANS: A Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The hierarchy for assessing pain consists of (1) obtaining a verbal report, which is not possible in this client, (2) consider conditions that might reasonably be painful, (3) observe behaviors, (4) evaluate physiologic indicators, and (5) attempt an analgesic trial. The client is not known to have any conditions that reasonably would cause pain. The nurse would next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean that the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case until the nurse has conducted a full assessment. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

ANS: A Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.

The postanesthesia care unit (PACU) nurse is caring for an older client following a lengthy surgery. The client's pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline. What assessment does the nurse make next? a. Temperature b. Level of consciousness c. Blood pressure d. Rate of IV infusion

ANS: A Bradycardia in the immediate postoperative client can indicate anesthesia effect or hypothermia. Older adults are at higher risk for hypothermia because of age-related changes in temperature regulation, decreased body fat, or prolonged exposure to cool environments, such as an OR suite. The nurse would first assess the client's temperature and take measures to correct any existing hypothermia. Level of consciousness, blood pressure, and IV infusion rate are not related, although all are important assessments in the postoperative period.

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

ANS: A The SCIP project contains core measures to reduce surgical complications. Examples of focus included administration of prophylactic antibiotics, correct hair removal processes, the timing of discontinuation of urinary catheterization after surgery, and venous thromboembolism prophylaxis. These practices are now standard in surgical care. Prevention of infection is a heavy emphasis, so the managers would start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the primary health care provider about a dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

ANS: A This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the primary health care provider about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.

A nurse learns older adults are at higher risk for complications after surgery. What reasons for this does the nurse understand? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes f. Slower reaction times

ANS: A, B, C, D, F Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output,decreased oxygenation of tissues, nocturia, mobility alterations, and slower reaction times.They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.

A nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.) a. Decreased immune response b. Development of chronic pain c. Increased gastrointestinal (GI) motility d. Possible immobility e. Slower healing f. Negative quality of life

ANS: A, B, D, E, F There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand. Decreased quality of life includes depression, anxiety, fear, anger, hopelessness, and insomnia; impaired family, work, and social relationships; and difficulty with ADLs.

A nurse is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

ANS: A, C, D, E Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

A nurse on the postoperative unit administers many opioid analgesics. Which actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) a. Avoid using other medications that cause sedation. b. Delay giving medication if the client is sleeping. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.

ANS: A, C, D, E Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse would identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client's oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.

A nurse is caring for several clients in the morning prior to surgery. Which medications taken by the clients require the nurse to consult with the primary health care provider about their administration? (Select all that apply.) a. Insulin b. Omega-3 fatty acids c. Phenytoin d. Metoprolol e. Warfarin f. Prednisone

ANS: A, C, D, E, F Although the client will be on NPO status before surgery, the nurse should check with the primary health care provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma,anticoagulation, or depression and steroids. Metformin is used to treat diabetes; phenytoin is for seizures; metoprolol is for cardiac disease and/or hypertension; and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. Which actions by the nurse are most appropriate? (Select all that apply.) a. Consult with the surgeon and voice objections. b. Delegate administration of the placebo to another nurse. c. Give the placebo and reassess the client's pain. d. Notify the nurse manager of the placebo prescription. e. Tell the client what medications were prescribed.

ANS: A, D Nurses would never give placebos to treat a client's pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse would voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse would not delegate giving the placebo to someone else, nor would the nurse give it. Telling the client about the placebo prescription before voicing objections would not be beneficial.

A client has received several doses of midazolam. The nurse assesses the client to be difficultto arouse with respirations of 6 breaths/min. What actions by the nurse are most important?(Select all that apply.) a. Administer oxygen per protocol. b. Obtain one dose of flumazenil. c. Obtain naloxone, 0.04 mg for IV push. d. Ensure suction is working e. Transfer the client to intensive care. f. Monitor client every 10 to 15 minutes for the next 2 hours.

ANS: A, D, E Midazolam is a benzodiazepine and its reversal agent is flumazenil. Naloxone is for opioid reversal. The nurse would apply oxygen as prescribed or by policy and obtain several doses at once because the drug can be given every 2 to 3 minutes if needed. Flumazenil can cause vomiting, so the nurse ensures suction equipment is present and working. Since flumazenil is metabolized more quickly than the midazolam, the client must be monitored every 10 to 15 minutes for the next 2 hours. The client may or may not need to be transferred.

A nurse learns the concepts of addiction, tolerance, and dependence. Which information is accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same thing. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease. f. Physical dependence occurs after repeated doses of an opioid.

ANS: A, D, E, F Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first? a. Client being discharged later on a complicated analgesia regimen. b. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. c. Postoperative client who received oral opioid analgesia 45 minutes ago. d. Client who has returned from physical therapy and is resting in the recliner.

ANS: B Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs at least 30 minutes for the oral medication to become effective and would be seen shortly to assess for effectiveness. The client going home requires teaching, which would be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client? a. Desipramine b. Duloxetine c. Morphine sulfate d. Nortriptyline

ANS: B Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, SNRIs are better tolerated than tricyclics, which eliminate desipramine and nortriptyline. Duloxetine would be the best choice for this older client.

A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 4 hours. b. Instruct the client to report any unrelieved pain. c. Monitor for numbness and tingling in the legs. d. Perform frequent neurologic assessments.

ANS: B Complications from intraspinal anesthesia are rare, but can be life threatening. The nurse would perform frequent neurologic assessments and notify the primary health care provider for abnormal findings. Vital signs are taken every 1 to 2 hours for at least 12 hours. Unreported pain is managed, but this is not a safety concern. Numbness and tingling outside of the surgical site is not normal, but can usually be abated by decreasing the opioid dose. The nurse can also keep the client on bedrest, decreasing safety concerns, while reporting to the primary health care provider.

A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? a. Hydrocodone and acetaminophen b. Hydromorphone c. Meperidine d. Tramadol

ANS: B Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse would not choose the combination with acetaminophen because it contains acetaminophen and the client has a history of alcoholism. Tramadol would not be used due to the potential for interactions with the client's sertraline. Meperidine is rarely used and is often restricted.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the primary health care provider. c. Have the client sign the consent, and then call the primary health care provider. d. Remind the client of what teaching the primary health care provider has done.

ANS: B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the primary health care provider. The nurse can repeat some facts taught by the primary health care provider, but this topic is too broad for the nurse to address alone. The nurse should notify the primary health care provider to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.

A nurse is giving a client instructions for showering the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Use the prescribed solution and wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Use warm water and scrub the surgical area vigorously."

ANS: B One or two days before the scheduled surgery, the surgeon may ask the patient to shower using an antiseptic solution, often chlorhexidine gluconate. This cleaning reduces contamination of the surgical field and the number of organisms at the site. Hair removal ifneeded is done in the operating suite using evidence-based practices such as clipping or a depilatory agent. While the client should wash the area thoroughly, vigorous scrubbing might scrape the skin, increasing the risk of infection

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the primary health care provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallow breaths. d. Tell the client that a little pain is expected.

ANS: B Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know that some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client's oxygen saturation is 87%. Which action would the nurse perform first? a. Apply oxygen at 4 L/min. b. Attempt to arouse the client. c. Give naloxone (Narcan). d. Notify the Rapid Response Team.

ANS: B The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client's respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.

The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a client. Which information provided by the nurse is most appropriate for the client's long-term outcome? a. "At least you know that the pain after surgery will diminish quickly." b. "Discuss acceptable pain control after your operation with the surgeon." c. "Opioids often cause nausea but you won't have to take them for long." d. "The nursing staff will give you pain medication when you ask them for it."

ANS: B The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself or herself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who smokes d. Client with severe heart failure e. Wheelchair-bound client f. 50 years of age or older

ANS: B, C, D, E All surgical clients should be assessed for VTE risk. Those considered to be at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility,or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery.

A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What action by the client indicates a need for further instruction? a. Client states "This will help prevent blood clots in my legs." b. Bends both knees, pushes against the bed until calf and thigh muscles contract. c. Dorsiflexes and plantar flexes each foot several times an hour. d. Makes several clockwise then counterclockwise ankle circles with each foot.

ANS: B The client should perform this leg exercise one leg at a time. The other actions are correct.

A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client's health history would lead the nurse to consult with the primary health care provider over the choice of medication? a. 25-pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin

ANS: B The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which would be investigated prior to prescribing chronic acetaminophen. The nurse would relay this information to the primary health care provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

ANS: B The skin is the body's first line of defense against infection and a drain of any type increases this risk. The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

ANS: B Vomiting after surgery has several complications, including aspiration. The nurse would listen to the client's lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.

A nurse is learning about different surgical procedures and their classifications. Which examples below does this include? (Select all that apply.) a. Rhinoplasty: curative b. Liver biopsy: diagnostic c. Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement:reconstructive d. Body contouring: cosmetic

ANS: B, C, D A cosmetic procedure is designed to improve the client's appearance or self-confidence; a body contouring procedure is an example. A diagnostic procedure is performed to determine the origin and cause of a disorder by taking a tissue sample with the intention of diagnosing(and staging, if applicable) a condition, such as a liver biopsy. A preventative procedure is performed with the intention that a specific condition will not occur. An example of this is a prophylactic bilateral mastectomy in a woman who carries the BRCA 1 or BRCA 2 gene to prevent the development of breast cancer. A palliative procedure is designed to improve quality of life; an example is an ileostomy. A reconstructive operation improves functional ability is an abnormal or damaged structure. A total shoulder replacement would be an example. A curative operation is performed to resolve a health problem by repairing or removing the cause; a gallbladder removal is an example.

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric(NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL (6.7 mmol/L) b. Hemoglobin: 7.8 mg/dL (78 mmol/L) c. pH: 7.68 d. Potassium: 2.9 mEq/L (2.9 mmol/L) e. Sodium: 142 mEq/L (142 mmol/L)

ANS: B, C, D Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting.The sodium level is normal.

Nurses at a conference learn the process by which pain is perceived by the client. Which processes are included in the discussion? (Select all that apply.) a. Induction b. Modulation c. Sensory perception d. Transduction e. Transmission f. Transition

ANS: B, C, D, E The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure that the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation. f. Assess the client for fall risks

ANS: B, C, D, E, F Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, assessing for fall risk, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided unless an oral medication is ordered to be given in pre-op

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

ANS: B, D, E Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics may be given to clients at risk for infection, but not all clients need them for 72 hours. Draining wounds would always be covered.

A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.) a. Ask for a physical therapy consult. b. Educate the client on cold therapy. c. Offer to provide a heating pad. d. Repeat the ice application. e. Teach the client relaxation techniques. f. Offer the client headphones with music.

ANS: B, D, E Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse would focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. Other nonpharmacologic methods to reduce pain include distraction, imagery, and mindfulness. A physical therapy consult will not help relieve acute pain of a fracture. Heat would not be a good choice for this type of injury.

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on? (Select all that apply.) a. Hemorrhage prevention b. Infection prevention c. Malignant hyperthermia testing d. Stroke recognition e. Thromboembolism prevention f. Correct hair removal

ANS: B, E, F The Surgical Care Improvement Project (SCIP), a set of core compliance measures, was initiated in 2006 to reduce surgical complications. Examples of focus included administration of prophylactic antibiotics to prevent infection, correct hair removal processes, the timing of discontinuation of urinary catheterization after surgery, and venous thromboembolism prophylaxis. These practices are now standard in surgical care.

A client had a surgical procedure with spinal anesthesia. The client's blood pressure was 122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Notify the primary health care provider. d. Nothing; this is expected.

ANS: C A widening pulse pressure (44 to 78 mm Hg) and nausea may indicate autonomic blockade, a complication of spinal anesthesia causing widespread vasodilation. The nurse would notify the primary health care provider. The Rapid Response Team is not yet warranted; the nurse would not increase the IV rate without a prescription.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale

ANS: C All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. A confused client with difficulty speaking would not be a good candidate for the numeric rating scale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES Pain Scale may not be appropriate for an adult client.

A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Client's self-report d. Objective observation

ANS: C Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client would the nurse see first? a. Client who is crying and agitated b. Client with a heart rate of 104 beats/min c. Client with a Pasero Scale score of 4 d. Client with a verbal pain report of 9

ANS: C The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse would see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

A registered nurse is caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA? a. Assesses the client's pain level per agency policy. b. Monitors the client's respiratory rate and sedation. c. Presses the button when the client cannot reach it. d. Reinforces client teaching about using the PCA pump.

ANS: C The client is the only person who should press the PCA button. If the client cannot reach it, the nurse would either reposition the client or the button, and would not press the button for the client. Pressing the button for the client ("PCA by proxy") indicates the need to review the information about this treatment modality. The other actions are appropriate.

A postoperative client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer? a. Flumazenil 0.2 to 1 mg b. Flumazenil 2 to 10 mg c. Naloxone 0.4 to 2 mg d. Naloxone 4 to 20 mg

ANS: C The nurse would prepare to administer naloxone, an opioid antagonist, at a dose of between 0.04 and 0.05 mg up to 2 mg, depending on the client's symptoms. Flumazenil is a benzodiazepine antagonist.

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post discharge care? a. Married young adult who is the primary caregiver for children. b. Middle-age client who is post-knee replacement, and needs physical therapy. c. Older adult who lives alone at home despite some memory loss. d. Young client who lives alone, and has family and friends nearby.

ANS: C The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed.The other clients all have evidence of a support system and no known potential for serious safety issues.

A preoperative nurse is reviewing morning laboratory values on four clients waiting forsurgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL (106.1 umol/L) b. Hemoglobin: 14.8 mg/dL (148 mmol/L) c. Potassium: 2.9 mEq/L (2.9 mmol/L) d. Sodium: 134 mEq/L (134 mmol/L)

ANS: C The potassium level is critically low and can affect cardiac and respiratory status. The nursewould communicate this laboratory value immediately. The creatinine is at the high end ofnormal, the hemoglobin is normal, and the sodium is only slightly low so these values do notneed to be reported immediately.

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

ANS: C The respiratory rate is the most important vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse would assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F (35.6° C) is slightly low and the client needs to be warmed.But none of these other vital signs take priority over the respiratory rate.

A registered nurse (RN) is watching a new nurse change a dressing and perform care around a Penrose drain. What action by the new nurse warrants intervention? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain's safety pin to the sheets d. Using sterile technique to empty the drain

ANS: C The safety pin that prevents the drain from slipping back into the client's body would not be pinned to the client's bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.

A postoperative nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next? a. Ability to raise head off the bed b. Blood pressure and pulse c. Signs of oxygenation d. Level of orientation

ANS: C When neuromuscular blocking agents are retained, muscle weakness could affect the diaphragm and impair gas exchange. Symptoms include the inability to maintain a head lift, weak hand grasps, and an abdominal breathing pattern. Since the client has weak hand grasps,the nurse would assess for signs of systemic oxygenation next. The nurse would assess headlift ability, but this does not take priority over oxygenation. Blood pressure, pulse, and level of orientation are all important in the postoperative period, but oxygenation would come first.

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. f. Some clients may be discharged directly after phase I.

ANS: C, D, E There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Some patients achieve this level of recovery in phase I and can be discharged directly to home. Phase II ends when the client is at a pre-surgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended-care environment and may continue at home or in an extended-care facility if needed.

A postoperative client has an epidural infusion of morphine and bupivacaine. Which actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Ask the client to point out any areas of numbness or tingling. b. Determine how many people are needed to ambulate the client. c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the client's vital signs per agency protocol.

ANS: C, D, E The AP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and would ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. "Are you worried about addiction to pain pills?" b. "Do you attach any spiritual meaning to pain?" c. "How high would you say your pain tolerance is?" d. "What pain rating would be acceptable to you?"

ANS: D A comprehensive pain assessment includes the items listed in the question plus the client's opinion on a comfort-function outcome, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

A nurse on the postoperative inpatient unit receives hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client would the nurse see first? a. Client who appears to be sleeping soundly. b. Client with no bolus request in 6 hours. c. Client who is pressing the button every 10 minutes. d. Client with a respiratory rate of 8 breaths/min.

ANS: D Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse would first check this client. The client "sleeping soundly" could be comfortable (no indicators of respiratory distress) and would be checked next. Pressing the button every 10 minutes indicates that the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse would next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment findings would lead the nurse to consult with the primary health care provider? a. Bilateral lung crackles b. Hypoactive bowel sounds c. Self-reported pain of 3/10 d. Urine output of 20 mL/2 hr

ANS: D Drugs in this category can affect renal function. Clients need to be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse would consult with the primary health care provider (PHCP) about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the PHCP.

The postoperative nurse is caring for a client who reports feeling "something popped" after vomiting. What action by the nurse is best? a. Administer an antiemetic medication. b. Call the primary health care provider. c. Instruct client to avoid coughing. d. Gather sterile non adherent dressings.

ANS: D The client may have a wound dehiscence. The nurse would gather needed supplies and assess the wound under the dressing. If the incision has dehisced, the nurse would cover it with a sterile non adherent dressing or saline-moistened gauze dressing then call the primary healthcare provider. The client may need an antiemetic, but this is not the most important action at this time.

A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority? a. Assessing fluid and blood out put b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

ANS: D Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The inpatient nurse and postanesthesia care nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority

A nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the charge nurse is best? a. "A multimodal approach is the preferred method of control." b. "Clients are consumers and they demand lots of pain medicine." c. "We are all much more liberal with pain medications now." d. "Pain is so complex it takes different approaches to control it."

ANS: D Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the newer nurse if the terminology is not understood. Primary health care providers and nurses may be more liberal with different types of pain medications, but that is not the best reason for this approach, especially in light of the opioid epidemic. Saying that clients are consumers who demand medications sounds as if the charge nurse is discounting their pain experiences.

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the client's care plan? a. As-needed pain medication after therapy b. Pain medications prior to therapy only c. Patient-controlled analgesia with a basal rate d. Round-the-clock analgesia with PRN analgesics

ANS: D Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A patient-controlled analgesia pump might be a good idea but needs bolus (intermittent) settings to accomplish adequate pain control, with or without a basal rate. Pain control needs to be continuous, not just administered prior to therapy.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

ANS: D Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but client safety is more important.

A nurse is assessing pain in an older adult. Which action by the nurse is best? a. Ask only "yes-or-no" questions so the client doesn't get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.

ANS: D Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, and then leaving, might give the impression that the nurse does not have time for the client. Also, the client may not know how to use it. There is no normal pain from aging.