Pain Case Study

After reviewing Ms. J's medication list, the nurse is most likely to question scheduled doses of which med? 1. naltrexone 2. fentanyl 3. morphine 4. acetaminophen

1

For Ms. R (RA), which discharge topic is most important to emphasize to prevent a major post op complication? 1. activity and movement limitations 2. continuation of pain meds 3. possibility of repeat surgery 4. expected post surgical symptoms

1

Mr. O is at risk for compartment syndrome b/c of the cast. Which pain assessment finding would alert you to this? 1. pain on passive motion 2. sudden increase in pain 3. intense discomfort r/t itching sensation 4. absence of pain despite no recent med

1

Ms. J is receiving opiates to control her pain caused by end-stage multiple myeloma. Which side effect is the major concern for this pt?1. constipation 2. resp depression 3. N/V 4. sedation

1

Which nonpharmacologic intervention for pain management is most appropriate for Mr. L (kidney stones)? 1. avoid over hydration or under hydration 2. massage lower back 3. darken rook for encourage rest 4. apply ice pack

1

Based on the info that the nurse received during handoff report for Mr. L (kidney stones) what is the priority concept to considering in planning interventions? 1. elimination 2. pain 3. fluid balance 4. infection

2

Based on the information that the nurse received during hand off report for Mr. A (bacterial pneumonia and HIV), what is the priority concept to consider in planning care? 1. Pain 2. Gas exchange 3. immunity 4. cellular regulation

2

Mr. A has a single-lumen PICC and he has the following scheduled meds and IV solutions that need to be given now: vancomycin 1.5 g in 250 mL of D5W over 90 mins; levofloxacin 750 mg in 150 mL of NS over 90 mins; D5W and 0.45% NaCl 1000 mL with 20 mEq of potassium at 125 mL/hr; and an IV bolus dose of morphine 3 mg. What is your priority action? 1. call the HCP and ask if the med times can be staggered 2. call the pharmacy and inquire about the compatibility of meds and solutions 3. give the bolus dose of morphine, b/c it will tak the least amount of time 4. establish an additional peripheral IV site

2

Mr. H is asking for pain med, and the HCP has ordered 10 mg of OxyContin PRN. The pharmacy has stocked 5-mg tabs of oxycodone immediate-release in the med cabinet. What is your first action? 1. call the HCP for clarification of the order 2. call the pharmacy and obtain the controlled-release form of the drug 3. ask the pt if immediate- or controlled-release action is preferred 4. give two of the 5-mg tabs to achieve correct dose

2

Mr. H returns from the OR following a hernia repair. He says that he is "afraid to walk b/c it will make the pain really bad." What will you explain as being the best option? 1. pain med q4h if he needs it 2. med 45 mins before ambulation or dressing changes 3. ATC pain med even if he has no report of pain 4. talking to the HCP for reassurance about the tx plan

2

Mr. H says h has several friends who became addicted to drugs an it ruined their lives. What is the nurse's best response? 1. your HCP prescribes opioids that do not cause addiction 2. you will be given opioids for a very short period of time and addiction is unlikely 3. your friends probably had addictive personalities 4. if you become addicted, you will be referred to rehab

2

Mr. L calls for pain meds. He describes the pain caused by kidney stone as excruciating. He is crying, diaphoretic, and pacing around the room. What is your priority action? 1. instruct him to do deep breathing 2. remind him to use PCA pump 3. give an "as needed" IV bolus dose 4. call the HCP immediately

3

Mr. L reports that the pain has decreased compared with earlier, but now he is having other s/s. Which symptom is of greatest concern? 1. painless hematuria with small clots 2. dull pain that radiates into genitalia 3. absence of pain but scant urine output 4. sensation of urinary urgency

3

Mr. O reports increasing pain in the right abdomen. On physical exam, you note hyperactive bowel sounds, a tense abdomen with guarding, and exquisite tenderness with gentle palpation. What is your priority action? 1. give a PRN pain med 2. notify HCP of your findings 3. take the complete set of VS 4. assist him to change positions

3

Ms. J is having severe pain and admits to it; however, she becomes very anxious when certain family members come and go and refuses to take the pain med. Which adjunct med would be most useful to Ms. J to help her manage these episodes? 1. naproxen (Naprosyn) 2. doxepin (Sinequan) 3. lorazepam (Ativan) 4. dicyclomine (Bentyl)

3

Which nonpharmacologic pain measure to help Ms. R (RA) relive her early morning stiffness should be delegated to the UAP? 1. assisting her into warm bath 2. sharing relaxation techniques 3. assisting her to warm shower 4. evaluate paraffin therapy effectiveness

3

The team leader decides to do a brief round of all the patients after shift report to ensure safety and to help determine acuity and assignments. List the order in which the team leader should briefly check in on these patients: 1. Ms. R (arthritis) 2. Mr. L (kidney stones) 3. Mr. O (motorcycle accident) 4. Mr. H (inguinal hernia repair) 5. Ms. J (end stage multiple myeloma) 6. Mr. A (bacterial pneumonia and HIV)

A, O, L, R, J, H 6, 3, 2, 1, 5, 4

Which morning tasks can be delegated to the UAP? (select all) 1. assist Ms. R, who has RA, with morning care 2. reinforce Mr. L, who has kidney stone, the need to save urine for straining 3. prepare Mr. H's room for his return from OR for hernia repair 4. report on condition of Mr. O's skin resulting from motorcycle accident 5. get coffee for Ms. J's (end-stage multiple myeloma) family 6. check on pulse ox reading for Mr. A, who has bacterial pneumonia

1, 2, 3, 5

Which of these 6 pts can be assigned to the new RN? (select all) 1. Ms. R (RA) 2. Mr. L (kidney stones) 3. Mr. O (motorcycle accident) 4. Mr. H (inguinal hernia repair) 5. Ms. J (end stage myeloma) 6. Mr. A (bacterial pneumonia and HIV)

1, 2, 4

Which end of shift tasks can be delegated to the UAP? (select all) 1. empty Ms. J's trash can and place personal items within reach 2. check Mr. A's linens for moisture and soiling and changing as needed 3. ask Mr. L if he needs a dose of pain meds prior to shift change 4. assist Ms. R to change position in bed to relive pressure on joints 5. ensure Mr. O's leg is elevated and evaluating comfort 6. empty Mr. A's urinal and record output

1, 2, 4, 6

Which tasks r/t to pain management can be dragged to the UAP? 1. reporting on grimacing seen in unresponsive pt 2. asking about location, quality, radiation 3. remind pt to report pain 4. observe for relief after med 5. ask if pt is having pain 6. determining is position change relieves pain

1, 3, 5

Ms. J's son tells the nurse his mom is having trouble breathing and a lot of pain. On assessment, she demonstrates shallow breathing and reports pain over the right lateral ribs that increases with movement breathing. What is the priority action? 1. take vitals with pulse ox and inform HCP 2. apply oxygen and raise HOB is pt in not hypotensive 3. obtain an order to start an IV and give morphine bolus 4. be calm, say with pt, encourage purse lipped breathing

2

Ms. R (RA) tells the nurse that she is dreading the post op exercises. She seems fearful and grimaces when the nurse suggests pain meds can be given prior. Which member of the HC team would the nurse consult first? 1. psych clinical nurse 2. OT 3. pharmacist 4. surgeon

2

The UAP reports that the new nurse is undermedicating the pts. What is the best way to handle this situation? 1. ignore her; the UAP is not qualified to judge an RN 2. ask the UAP to give specific examples 3. go to the new nurse and question her 4. do an assessment on all the nurse's pts

2

The new nurse tells you she cannot find any documentation that shows the time of Mr. L's (kidney stone) last dose of pain med. What action should occur first? 1. help the new nurse look at the chart and MAR 2. tell the new nurse to ask the night nurse before she leaves 3. speak to the night shift nurse about documentation 4. have the new nurse ask Mr. L when he last had med

2

Later in the shift, Mr. A (bacterial pneumonia) reports that the chest pain is gone but his back really hurts and that he needs more morphine. Based on the ethical principle of nonmaleficence, what is the nurse's priority action? 1. believe Mr. A's subjective report and give ordered med 2. contact HCP for increase in dosage because he appears to need higher doses 3. consider hx of addiction and chronic pain, respiratory status, and time of last dose 4. offer non pharmacological measures such as position change

3

During the shift, the following events occur at the same time. Prioritize the order for addressing these problems. 1. Mr. L is calling out loudly about right-sided flank pain caused by kidney stone 2. Mr. O, who was in motorcycle accident, is calling, "The pump tipped over and it's broken" 3. another nurse needs opioid wastage witnessed 4. Mr. A, with bacterial pneumonia, is urinating in the corner of his room

2, 1, 4, 3

Which tasks r/t to Mr. A's (bacterial pneumonia) pain management can be delegated to the UAP? select all that apply 1. clean the TENS unit 2. notify the nurse about pt request for pain meds 3. reinforce the use of pillow to splint when coughing 4. observe for actions that increase fatigue or anxiety 6. assist the patient to change position every 2 hours

2, 3, 6

At the end of the shift, the opioid count shows that two tablets of OxyContin are unaccounted for. You have spoken to all the nurses and pharmacists who had access to the med cabinet during the shift, but no one will admit to removing these two tablets. What should you do? (select all) 1. inform the staff that no one can leave until the matter is resolved 2. fill out an incident report and include facts about what you found and what you did 3. interview all of the pts who have orders for OxyContin 4. discuss the matter with the unit manager and review potential problems of the current system 5. review available records of access and med retrieval for the past 24 hrs 6. ask the staff if they saw any other people (students, HCP, instructors) who may have accessed the cabinet during the shift

2, 4, 5, 6

For Mr. O, in addition to pain meds, which action will help the most to relieve pain associated with the tibia-fibula fracture caused by motorcycle accident? 1. instruct him to periodically move his toes 2. use diversional therapy 3. elevate injured leg above heart 4. place pt in high Fowler's

3

It is the end of the shift and the new nurse is trying to give pain meds to one pt, provide comfort measures for another pt, and redo pain assessments on all her pts. Her documentation is incomplete. What should you do? 1. offer to help her by performing the comfort measures 2. let her struggle through so she can find her own way 3. help her prioritize and delegate the tasks 4. ask someone from the oncoming shift to help her

3

Mr. H (OR inguinal repair) is given a dose of pain med. One hour later he is anxious and appears uncomfortable and asks, "What's the matter, is something wrong, I'm still hurting." What action should you take first? 1. call HCP for change in med or dose 2. initiate NPO status in case surgery is needed 3. check for bladder distention and last voiding 4. reassure the pt that the hernia is not recurring

3

You are giving end of shift report about Ms. R (RA) to the oncoming nurse. Place the following info in correct order. 1. she had shoulder pain 4/10 and was reluctant to move around 2. do you have any questions for me 3. Ms. R is a 55 yo woman 4. she had shoulder arthroplasty 3 days ago 5. she received a PRN dose of tylenol with codeine, and pain is now 1/10 6. the PT must speak to Ms. R's daughter so page him when she arrives

3, 4, 1, 5, 6, 2

Mr. A reports left-sided anterior chest pain. What is your priority action? 1. obtain order for ECG and continuous tele monitoring 2. auscultate the lung fields and compare to baseline assessments 3. give a PRN pain med and reevaluate after 30 mins 4. ask him to describe the pain and measure all VS

4

Ms. J's son repeatedly insists that Ms. J is not getting enough pain med. He threatens to sue. You have used therapeutic communication skills with the son and advocated for the pt with the HCP. The HCP says to you, "I'll be in tomorrow, just tell the son to chill out." What is your best action? 1. call another HCP 2. continue to use current orders 3. have the son call the HCP 4. notify the unit manager

4

One of the staff members is talking about Mr. A, who has bacterial pneumonia, in the med room. "He complains all the time about pain everywhere. Well, he is going to have pain. He's a drug addict, so what does he expect?" What is your best response to this comment?1. all pts have right to care regardless of race, creed, or other traits 2. i'll take Mr. A; i don't mind taking care of him 3. you should think about how he really feels 4. what can we do to help Mr. A cope with his pain?

4

The nurse reinforces teaching about the purpose and correct use of the PCA with Mr. O and his mom. Both express an understanding and willingness to comply. When is the best time for Mr. O to activate the PCA? 1. when pain is a 5 2. 30 min after waking up and 30 min before bed 3. as soon as lockout time expires if pain is still present 4. 10 min before a painful procedure

4

The oncoming team leader asks the night shift nurse if anyone spoke to the mother about pushing the PCA button for Mr. O. The night shift nurse states "the mother is just concerned about her son and wants him to have pain relief. Besides, the prescribed dose is controlled by the pump". What is the team leader's best action? 1. report the night shift nurse to the unit manager 2. explain the purpose and function of the PCA to the mother 3. give the night nurse written info about the dangers of possible overdose 4. first talk to night nurse about PCA procedure, then talk to the mother

4

You are preparing to give Mr. L pain meds, but you note that the IV site is infiltrated, so you inform him that the IV catheter will have to be reinserted. He yells at you, "What's wrong with you people?! Can't you do anything right?!" What is the best response? 1. let me call the HCP and i can get an order for an oral med 2. this is not my fault, but if you will just give me a couple of mins i can fix it 3. let me call the nursing supervisor and you can talk to her about the situation 4. i know you are having pain. let me restart your IV line right now

4

You are talking to Ms. R (RA) about discharge plans and follow-up appointments. She begins to cry and says, "I was so active and athletic when I was younger." What is the most appropriate therapeutic response? 1. your shoulder will get progressively better with time and patience. don't cry. 2. i can see that you are really upset. is your shoulder hurting a lot right now? 3. i know what you mean. i used to be able to do a lot more when i was younger too. 4. it is difficult to deal with changes. what types of activities did you used to do?

4