Pain Management Practice Questions

4 If the pain is constant, the best schedule is around-the-clock to provide steady analgesia and pain control. The other options may require higher dosages to achieve control

What is the best way to schedule medication for a client with constant pain? 1. As needed (PRN) at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around-the-clock

1 The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside.

When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the client is pain free or acceptable level is reached. 3. Titrate downward to prevent toxicity, overdose, and adverse effects. 4. Titrate to a dosage that is adequate to meet the client's subjective needs.

3 Diaphoresis is one of the early signs that occurs between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal. Test Taking Tip: In studying for NCLEX®, pay attention to early signs of disease processes. Early detection is considered a safety measure; therefore, NCLEX® tests to determine if you can perform early identification of potential problems

A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps

B Long-acting or sustained-release opioids are dosed on a scheduled basis, not prn, to provide a base of continuous opioid analgesia.

A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? A. The drug B. The time interval C. The dose D. The route

1 Opioids can cause nausea and vomiting because of the action on the brainstem centers. This side effect decreases with repeated use, but until then, treatment for nausea should be instituted. Decreasing the dose may be ineffective for pain relief. Asking the patient to wait for pain relief is unethical. Withholding the dose may increase the pain.

A patient complains of nausea after receiving the first dose of morphine for pain. What should the nurse do? 1 Treat nausea with an anti-nausea medication and continue to use morphine 2 Request an order for a nonsteroidal anti-inflammatory drug (NSAID) instead of morphine. 3 Encourage the patient to wait as long as possible for the next dose. 4 Withhold the next dose of morphine until reevaluated by the health care provider.

1 PCA allows the patient to self-administer analgesic medication whenever needed. There is no risk of overdosage due to the programming. Opioids can be safely administered using PCA. It allows intravenous or subcutaneous administration of medications.

A patient has had arthritic pain for 8 years and has surgery to remove a buildup of septic fluid. Postoperative, the patient received morphine through a patient-controlled analgesia (PCA) device for the management of pain. What is the advantage of PCA that the nurse should teach the patient? 1 PCA allows self-administration of analgesics. 2 PCA is associated with a risk of overdose. 3PCA does not allow administration of opioids. 4 PCA allows intramuscular administration of medications.

C Constipation is a common opioid-related side effect, and patients do not become tolerant to it.

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? A. Opioid antagonists B. Antiemetics C. Stool softeners D. Muscle relaxants

2 Patients usually become tolerant to the side effects of opioids, with the exception of constipation. Routinely administering stimulant laxatives, not simple stool softeners, will prevent and treat constipation in these patients.

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1 Stool softener 2 Stimulant laxative 3 H2 receptor blocker 4 Proton pump inhibitor

A Patient's self-report of pain. Sleep is not an indicator of pain intensity. Unless a patient is stimulated, it is difficult to distinguish sleep from sedation, which may occur as a side effect of the opioid. Patients in pain sometimes sleep from exhaustion.

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? A. Patient's self-report B. Behaviors C. Surrogate (wife) report D. Vital sign changes

3 Prostaglandins are generated from the breakdown of phospholipids of the cell membrane and are known to increase pain sensitivity. NSAIDs act by decreasing the levels of such compounds in the blood. Renin is involved in balancing water and electrolytes in the body. Neurotransmitters such as serotonin inhibit the transmission of pain. Diclofenac sodium is a painkiller that reduces pain sensitivity.

A student nurse is reading about the mode of action of nonsteroidal anti-inflammatory drugs (NSAIDS). The NSAID drug decreases the level of a chemical that is known to increase pain sensitivity. With which chemical does the NSAID react? 1 Renin 2 Serotonin 3 Prostaglandin 4 Diclofenac sodium

2 Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff must rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns

For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Note the time of and client's response to the last dose of analgesic. 4. Give the maximum as needed (PRN) dose within the minimum time frame for relief.

3 The client must be believed, and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to the other options in developing the treatment plan

In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. Client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed.

1 The UAP can assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.

In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

4 A physician may first recommend acetaminophen to this patient because the pain is mild, and acetaminophen is relatively safe and widely available over the counter for musculoskeletal pain. The physician may prescribe aspirin, naproxen, or ibuprofen, but these may be second-choice drugs because they are nonsteroidal antiinflammatory drugs which carry a risk for bleeding, especially in older adults, and may not be necessary if the pain is mild.

A 65-year-old patient is experiencing mild musculoskeletal pain. Which drug is the primary health care provider most likely to prescribe? 1 Aspirin 2 Naproxen 3 Ibuprofen 4 Acetaminophen

4 Measuring output and obtaining a specimen are within the scope of practice of the UAP. Insertion of the indwelling catheter in this client should be done by an experienced RN because clients with obstruction and retention are usually very difficult to catheterize, and the nurse must evaluate the pain response during the procedure. The UAP's knowledge of sterile technique or catheter insertion is not the issue

A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced unlicensed assistive personnel (UAP) states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a specimen

1 This client has strong beliefs and emotions related to the issue of the brother's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, and their beliefs about drug addiction may be similar to those of the client

A client is crying and grimacing but denies pain and refuses pain medication because "my brother is a drug addict and has ruined our lives." What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 4. Seek family assistance in resolving this problem.

2 The UAP has correctly reported findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on assessment findings, the other options may also be appropriate

A client received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that the client has a respiratory rate of 10 breaths/min. What is the priority action? 1. Call the health care provider to obtain an order for naloxone. 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20 breaths/min. 4. Double-check the prescription to see which drugs were ordered.

4 The charge nurse must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Test Taking Tip: The first step of nursing process is assessment. In this case, the charge nurse applies nursing process to assess the nursing staff's performance and attitudes.

A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the staff nurses to assess their care of this client.

3 Responding to the client and family in a timely fashion is important. Next, directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next

A client's family member comes to the nurse's station and says, "He needs more pain medicine. He is still having a lot of pain." What is the nurse's best response? 1. "The health care provider (HCP) ordered the medicine to be given every 4 hours." 2. "If medication is given too frequently, there are ill effects." 3. "Please tell him that I will be right there to check on him." 54 4. "Let's wait about 40 minutes. If there he still hurts, I'll call the HCP."

3 Fentanyl is an opioid analgesic and is available for intravenous or transdermal administration. It is 100 times more potent than morphine. However, transdermal patches are not effective in patients weighing less than 100 pounds, because these patients have very little subcutaneous tissue for absorption. Therefore, the nurse should discuss a more appropriate analgesic drug with the primary health care provider. The dose and the number of patches for the therapeutic action are predetermined. The duration of drug action is about 48 to 72 hours.

A patient who is in the terminal stages of liver cancer reports continuous vomiting after taking oral opioid analgesics. The patient's weight is 85 pounds. The nurse applies a transdermal fentanyl patch to the patient. The next day, the patient informs the nurse that the pain is not alleviated. What could be the possible reason for this? 1 The dose of pain medication is not enough. 2 The number of patches used is not enough. 3 The route of administration of the analgesic is not correct. 4 The patient needs to wait longer for the medication to act.

D The common symptoms of opioid withdrawal that are associated with physical dependence may develop when an opioid is withdrawn rapidly. Symptoms include shaking chills, abdominal cramps, and joint pain.

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Opioid toxicity. B. Opioid tolerance. C. Opioid addiction. D. Opioid withdrawal.

3 While there is little risk for overdose with patient-controlled analgesic pumps, respiratory depression is a side effect associated with opioids, so while the patient is on opioid pain management, the nurse should regularly check respiratory rate. A nurse may check liver enzymes in a patient who is taking acetaminophen, not opioids, because acetaminophen can adversely affect the liver. Whereas blood pressure and body temperature may be checked regularly, it is unlikely that the nurse is doing this to monitor for side effects of opioid pain management.

A physician put a postoperative patient on a patient-controlled opioid analgesic pump to be used around the clock for a week. Which assessment should the nurse make at regular intervals? 1 Liver enzymes 2 Blood pressure 3 Respiratory rate 4 Body temperature

A A pain assessment is still needed because sleep in a postoperative patient cannot be used as an assessment of a patient's pain level. Sleep may result from sedating effects of medication, but analgesia may not be present. It is important to wake and assess the patient to ensure that the pain is controlled and the patient is not overly sedated from the medication (a sign of impending respiratory depression).

A postoperative patient currently is asleep. Therefore the nurse knows that: A. The sedative administered may have helped him sleep, but it is still necessary to assess pain. B. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. C. Pain assessment is not necessary. D. The patient can be switched to the same amount of medication by the oral route.

2, 5 Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, act by inhibiting prostaglandin synthesis, thereby inhibiting cellular response to inflammation and thus reducing pain. Gastrointestinal bleeding is a major adverse effect of NSAIDs. The remaining statements are incorrect. Opiates, not NSAIDs, depress the central nervous system to relieve pain. Because of the risk for gastrointestinal bleeding, ibuprofen and other NSAIDs are not frequently the first choice for treating pain in older adults. Ibuprofen is not a prescription drug; it is widely available over the counter.

A primary health care provider recommends ibuprofen to a patient in pain. Which statements about this medication are correct? Select all that apply. 1 It depresses the central nervous system in order to relieve pain. 2 It acts by inhibiting the synthesis of prostaglandins. 3 It is highly recommended for older adults experiencing pain. 4 It is the most effective prescription drug available for pain relief. 5 One of its serious side effects is gastrointestinal bleeding

1 Opioids, not nonsteroidal antiinflammatory drugs (NSAIDs), depress the central nervous system. The other statements indicate effective teaching: NSAIDs inhibit prostaglandin synthesis, which inhibits cellular responses to inflammation; this helps relieve pain. An allergy to aspirin may be indicative of an allergy to other NSAIDs, and NSAIDs may put older adults at an increased risk for gastrointestinal bleeding.

A registered nurse is teaching a nursing student about using nonsteroidal antiinflammatory drugs (NSAIDs) for pain management. Which of the nursing student's statements indicates a need for further teaching? 1 "NSAIDs work by depressing the central nervous system." 2 "NSAIDs act by inhibiting the synthesis of prostaglandins." 3 "Patients allergic to aspirin are more likely to be allergic to other NSAIDs." 4 "Use of NSAIDS in older adults may result in increased risk of adverse events."

4 The nurse has taken the first correct step and compared the MAR to the HCP's original prescription. Because the nurse is new, the charge nurse would be the best resource. In fact, larger PCA doses are given at night to increase the interval between doses. This helps the client to rest and sleep. The nurse can contact the other members of the health care team at any time if the charge nurse is unable to help.

An inexperienced graduate nurse is reviewing the medication administration record (MAR) for a client who has a patient-controlled analgesia (PCA) pump for pain management. The new nurse compares the MAR and the health care provider's (HCP's) prescription, and both indicate that larger doses are prescribed at night compared with doses throughout the day. Which member of the health care team should the new nurse consult first? 1. Ask the client if he typically needs extra medication in the evening. 2. Ask the HCP to verify that the larger amount is the correct dose. 3. Ask the pharmacist to confirm the dosage on the original prescription. 4. Ask the charge nurse if this is a typical dosage for nighttime PCA.

2 The duration of action or half-life of naloxone is less than that of methadone. Therefore, recurrence of respiratory depression by the relatively long action of methadone can be prevented by reassessing the patient every 15 minutes for 2 hours after naloxone administration. Methadone has a greater half-life than naloxone. Therefore, the effect of methadone is more prolonged than that of naloxone. Naloxone is an opioid-antagonist drug. Naloxone does not act as an agonist to morphine after 2 hours. Opioid-naïve patients are patients who have not taken opioid medications for at least a week. Naloxone causes morphine withdrawal symptoms only in patients who are physically dependent on morphine, not the patients who are opioid naïve.

An opioid-naïve patient is on naloxone for respiratory depression caused by methadone overdose. The nurse is instructed to reassess the patient every 15 minutes for 2 hours following drug administration. What is the reason behind the schedule of reassessment of the patient? 1 The half-life of naloxone is greater than that of methadone. 2 Duration of the action of naloxone is less than that of methadone. 3 Naloxone acts as an agonist to methadone after 2 hours of administration. 4 Naloxone can cause methadone withdrawal symptoms in an opioid-naïve patient.

1 The nurse asks questions such as, "Can you tell me what your discomfort feels like?" to assess the quality of pain. To identify the severity of pain, the nurse can ask, "On a scale of 0 to 10, how bad is your pain now?" To identify the onset and duration of pain the nurse can ask, "When did your pain start?" To identify the intensity of pain the nurse can ask, "How much pain do you have now?"

During the subjective data collection for pain assessment, the nurse asks the patient, "Can you tell me what your discomfort feels like?" What is the reason for this question? 1 The nurse wants the patient to identify the quality of pain. 2 The nurse wants the patient to identify the severity of pain. 3 The nurse wants the patient to identify the duration of pain. 4 The nurse wants the patient to identify the intensity of pain.

3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension.

Family members are encouraging the client to "tough out the pain" rather than risk drug addiction to opioids. The client is stoically abiding. The nurse recognizes that the sociocultural dimension of pain is the current priority for the client. Which question will the nurse ask? 1. "Where is the pain located, and does it radiate to other parts of your body?" 2. "How would you describe the pain, and how is it affecting you?" 3. "What do you believe about pain medication and drug addiction?" 4. "How is the pain affecting your activity level and your ability to function?"

3 The nurse is weighing benefit against harm. If client is a drug abuser, the medication given in the hospital is not harming him. If the client is not a drug abuser, then withholding the medication causes him to suffer pain because of unconfirmed suspicions. The nurse must also remember that medical use of opioids does not cause addiction and for clients who are addicted, withholding medication in the hospital setting does not resolve the addictive behavior.

For a postoperative client, the health care provider (HCP) prescribed multimodal therapy, which includes acetaminophen, nonsteroidal antiinflammatory drugs, as needed (PRN) opioids, and nonpharmaceutical interventions. The client continuously asks for the PRN opioid, and the nurse suspects that the client may have a drug abuse problem. Which action by the nurse is best? 1. Administer acetaminophen and spend extra time with the client. 2. Explain that opioid medication is reserved for moderate to severe pain. 3. Give the opioid because client deserves relief and drug abuse is unconfirmed. 4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription.

3 The client with cancer needs morphine for symptom relief. For obstetric clients, morphine can suppress fetal respiration and uterine contractions, so regional or epidural methods are preferred. For head injuries, morphine could make evaluation of mental status more difficult. In addition, if respirations are depressed, intracranial pressure could increase. Opioids are usually not the first-line choice for chronic pain, and opioids must be used with caution in older adult clients because of changes related to aging, such as renal clearance. In addition, use of opioids increases risk for falls and contributes to constipation

For which of these clients is IV morphine the first-line choice for pain management? 1. A 33-year-old intrapartum client needs pain relief for labor contractions. 2. A 24-year-old client reports severe headache related to being hit in the head. 3. A 56-year-old client reports breakthrough bone pain related to multiple myeloma. 4. A 73-year-old client reports chronic pain associated with hip replacement surgery.

4 Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps. Test Taking Tip: During clinical rotations, you may observe nurses giving pain medication without performing an adequate pain assessment. This is an error in clinical performance. In postoperative clients, pain could signal complications, such hemorrhage, infection, or decreased perfusion related to tissue swelling. Always assess pain first; then make a decision about giving medication, using nonpharmacologic methods, or contacting the HCP.

On the first day after surgery, a client receiving an analgesic via patientcontrolled analgesia pump reports that the pain control is inadequate. What is the first action that the nurse should take? 1. Deliver the bolus dose per standing order. 2. Contact the health care provider (HCP) to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity.

2 This statement is a veiled suicide threat, and clients with pain disorder and depression have a high risk for suicide. New injuries must be evaluated, but this type of pain report is not uncommon for clients with pain disorder. Risk for substance abuse is very high and should eventually be addressed. The client can always threaten to sue, but the nurse must remain calm and continue to provide care with professional courtesy.

Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, "None of these doctors has done anything to help." Which client statement is cause for greatest concern? 1. "I twisted my back last night, and now the pain is a lot worse." 2. "I'm so sick of this pain. I think I'm going to find a way to end it." 3. "Occasionally, I buy pain killers from a guy in my neighborhood." 4. "I'm going to sue you and the doctor; you aren't doing anything for me."

4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists

The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for documenting dose and time and discuss documentation deficits

3 Pain assessment is very complex, but the consistent use of the same assessment tool is the best method. The nurse should use all tools in conjunction with observation, clients' self-report, and other assessment skills. When a client is engaged in an activity, behavior may not accurately reflect pain. Asking a client to point to the pain is only one part of the total pain assessment. Relatives of confused clients can assist the nurse to recognize the meaning of behaviors, but they are not able to describe pain sensations for the client

The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain? 1. Nurse A uses a behavioral assessment tool when the client is engaged in activities. 2. Nurse B asks a client who doesn't speak English to point to the location of pain. 3. Nurse C uses the same numerical rating scale every day for the same client. 4. Nurse D asks the daughter of a confused client to describe the client's pain.

1 All of these behaviors require correction; however, heat can increase the release of medication from the patch and result in a sudden overdose. The client should be urged to rotate sites to prevent irritation of the skin. Reusing old patches and delaying the patch changes are likely to give less than optimal pain relief. Based on assessment of behaviors, the nurse would reeducate about use of the patch, help the client seek financial resources, or develop a reminder system for patch change intervals.

The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction? 1. Frequently likes to sit in the hot tub to reduce joint stiffness 2. Prefers to place the patch only on the upper anterior chest wall 3. Saves and reuses the old patches when he can't afford new ones 4. Changes the patch every 4 days rather than the prescribed 72 hours

4 Administering placebos is generally considered unethical. (There are circumstances, such as clinical drug research where placebos are used, but clients are aware of that possibility.) The charge nurse is a resource person who can help clarify the situation and locate and review the hospital policy. If the HCP is insistent, suggest that he or she could give the placebo. (Note: Use "could," not "should," when talking to the HCP. This provides a small opportunity to rethink the decision. "Should" elicits a more defensive response.) Although following a personal ethical code is correct, the nurse must ensure that the client is not abandoned and that care continues

The health care provider (HCP) has ordered a placebo for a client with chronic pain. The newly hired nurse feels very uncomfortable administering the medication. What is the first action that the new nurse should take? 1. Prepare the medication and hand it to the HCP. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice and suggestions

3 If the social worker can assist the family to find affordable alternatives, then the father is more likely to stop giving his medication to the daughter

The home health nurse discovers that an older adult client has been sharing his pain medication with his daughter. Despite the nurse's warnings about the dangers of sharing, he states, "My daughter can't afford to see a doctor or to buy medicine, so I must give her a few of my pain pills." Which member of the health care team is the nurse most likely to consult first? 1. Health care provider to renew the prescription so that client has enough medicine 2. Pharmacist to monitor the frequency of the prescription refills 3. Social worker to help the family locate resources for health care 4. Home health aide to watch for inappropriate medication usage by family

4 One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions

The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports "feeling pretty good,except for the pain and stiffness in my joints when I first get out of bed." Which member of the health care team would be the most appropriate to aid in the client's report of pain? 1. Health care provider to review the dosage and frequency of pain medication 2. Physical therapist for evaluation of function and possible exercise therapy 3. Social worker to locate community resources for complementary therapy 4. Unlicensed assistive personnel to help client with a warm shower in the morning

2 Pain extending from the initial site of injury to another body part is radiating pain. Therefore, because the patient has pain in the back accompanied by pain in the leg, it indicates radiating pain. Pain resulting from stimulation of the skin is cutaneous pain. A patient with pain from a small cut or laceration has cutaneous pain. If the patient has pain at one site but injury at a different site, it indicates referred pain. A patient experiencing a crushing sensation with pain in chest and a burning sensation with severe stomach pain indicates referred pain.

The nurse concludes that a patient has radiating pain. Which assessment findings support the nurse's conclusion? 1 The patient has pain from a small cut or laceration. 2 The patient has pain in the back accompanied by pain in the leg. 3 The patient has a crushing sensation with pain in the chest. 4 The patient has a burning sensation with severe stomach pain

2 Most adverse opioid events are preceded by an increased level of sedation

The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction? 1. Client reports shortness of breath. 2. Client is more difficult to arouse. 3. Client is more anxious and nervous. 4. Client reports pain is worsening.

2, 3, 4 A patient in acute pain may not be able to concentrate on anything. The patient may have a reduced attention span and may focus only on pain relief. The nurse may observe the patient clenching teeth or biting his or her lips to tolerate or suppress the pain. These patients are usually physically restless due to pain and they do not interact or talk incessantly.

The nurse is attending to a postsurgical patient who underwent a nephrectomy. What observations would tell the nurse the patient is in severe pain? Select all that apply. 1 The patient is motionless. 2 The patient has a reduced attention span. 3 The patient is constantly asking for pain relief medication. 4 The patient has clenched teeth and is biting his or her lips. 5 The patient is talking incessantly for a long time.

1 Multimodal therapies for postoperative clients include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies. This approach is thought to be the most important strategy for pain management for most postoperative clients. Standing orders are less optimal because there is no consideration of individual needs or characteristics. PCA is one important element, but not all clients can manage PCA devices. Assessment tools are an important part of overall management, but basing opioid dose on a numerical scale does not consider individual client circumstances

The nurse is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best? 1. Multimodal strategies 2. Standing orders by protocol 3. Intravenous patient-controlled analgesia (PCA) 4. Opioid dosage based on valid numerical scale

2 Explain that insulin is a priority because life-threatening ketoacidosis may already be in progress. If she is already aware of the dangers of an elevated BG level, then her refusal suggests ongoing suicidal intent and the provider should be notified so that steps can be taken to override her refusal (potentially a court order). A BG level of over 600 mg/dL (33.3 mmol/L) is typically a criterion for transfer to intensive care, but making arrangements for transfer is time consuming, and treatment of the elevated BG should begin as soon as possible. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of elevated BG and possible ongoing suicidal intent.

The nurse is caring for a young client with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action? 1. Notify the charge nurse and make arrangements to transfer to intensive care. 2. Explain significance of BG and insulin and then call the health care provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin.

3 Assessing the pain is the priority in this acute care setting because there is a risk of infection or hemorrhage. The other options might be appropriate based on the assessment findings.

The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The client begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." What is the best response? 1. "Let me stop the pump, and we can try oral pain medication to see if it relieves the pain." 2. "I realize that you are scared of the pain, but we must try to wean you off the pump." 3. "Show me where your pain is and describe how it feels compared with yesterday." 4. "Let's take your vital signs; then I will discuss your concerns with the health care provider."

1 The nurse would consider questioning all of the medication prescriptions, but the opioid-naïve adult has the greatest immediate risk, because use of a basal dose has been associated with an increased incidence of respiratory depression in opioid-naïve clients. Older adults are frequently prescribed NSAIDS; however, they are used with caution, and the client's history should be reviewed for potential problems, such as a history of gastrointestinal bleeding, cardiac disease, or renal dysfunction. Many medications such as anticoagulants, oral hypoglycemics, diuretics, and antihypertensives can also cause adverse drug-drug interactions with NSAIDs. IM injections cause pain, absorption is unreliable, and there are no advantages over other routes of administration routes. If a client is able to tolerate oral foods and fluids, oral medications are preferred because the efficacy of the oral route is equal to the IV route. Test Taking Tip: It is worthwhile to study the purposes, pharmacologic actions, and side effects of commonly used medications. Morphine is considered the prototype of the opioid medications. For opioid-naïve clients, the priority concern is respiratory depression. For clients who need opioids for long-term pain management, the primary side effect is constipation.

The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern? 1. A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia (PCA). 2. A 65-year-old adult will be discharged with a prescription for nonsteroidal anti-inflammatory drugs (NSAIDS). 3. A 25-year-old adult is prescribed as needed intramuscular (IM) analgesic for pain. 4. A 45-year-old adult is taking oral fluids and foods has orders for IV morphine.

1, 2, 3 The nurse should teach the patient about PCA and evaluate the patient's understanding by asking the patient to repeat what the nurse has taught. The patient should control the administration of the medication based on the pain. The device is programmed to prevent overdose. The family members should not operate the PCA device for the patient because the dose depends on the patient's perception of pain. The patient should be taught the use of the device before the procedures in order to be ready to administer the analgesia after awakening from sedation.

The nurse is teaching a patient the use of patient-controlled analgesia (PCA). Which interventions should the nurse perform? Select all that apply. 1 Ask the patient to describe the purpose of the PCA device. 2 Emphasize that the patient controls medication delivery. 3 Explain that the pump prevents the risk of overdose. 4 Tell family members to operate the PCA device for the patient. 5 Teach the use of PCA after the patient awakens from sedation

1 According to the American Society for Pain Management Nursing, prescribing opioid medication based solely on pain intensity should be prohibited because there are many other factors to consider (e.g., age, health conditions, medication history, respiratory status). Age, small body mass, and underlying respiratory disease put the 73-year-old client at greatest risk for overmedication and respiratory depression. Clients with history of opioid addiction will have a different response to medication and may need higher doses to achieve relief. IV morphine may actually worsen migraine headaches, and other first-line drugs (metoclopramide and prochlorperazine and subcutaneous sumatriptan) are more effective. Hydromorphone is not typically prescribed for the pain associated with chronic of rheumatoid arthritis

The nurse is working with a health care provider who prescribes opioid doses based on a specific pain intensity rating (dosing to the numbers). Which client circumstance is cause for greatest concern? 1. A 73-year-old frail female client with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10. 2. A 25-year-old postoperative male client with a history of opioid addiction is prescribed one tablet of oxycodone and acetaminophen for pain of 4 to 5 on a scale of 0 to 10. 3. A 33-year-old opioid-naïve female client who has a severe migraine headache is prescribed 5 mg IV morphine for pain of 7 to 8 on a scale of 0 to 10. 4. A 60-year-old male with a history of rheumatoid arthritis is prescribed one tablet of hydromorphone for pain of 5 to 6 on scale of 0 to 10

4 The LPN/LVN is well trained to administer oxygen per nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy.

The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

1 Nonmaleficence is to prevent harm. If the client is excessively sedated, the nurse knows that giving additional opioid medication could do more harm than good, so the nurse would conduct further assessments and seek alternative options for pain relief. The client's report of pain should be believed, so based on the principle of justice, the nurse advocates for pain medication even though an organic cause of disease is not identified. By encouraging the client to have a voice in her or his own pain management goals, the nurse is applying the principle of autonomy. By explaining the benefits of pain medication, the nurse is applying the principle of beneficence to help the client recognize the balance between pain control and safety.

The nurse recognizes that there are ethical considerations in helping clients to achieve relief from pain. Which nursing action is the best example of the principle of nonmaleficence? 1. Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. 2. Client has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine. 3. Client is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the client to verbalize personal goals for pain management. 4. Client repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication

C The Food and Drug Administration (FDA) recommends a maximum daily dose of 4 g of acetaminophen, and many authorities believe that the maximum daily dose should be lower (3000 to 3200 mg/day) in the outpatient setting to reduce the risk of hepatotoxicity.

The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received acetaminophen 2Gs, two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? A. The patient's level of pain B. The potential for addiction C. The amount of daily acetaminophen D. The risk for gastrointestinal bleeding

2 Opioid analgesics are effective when used for pain management, but a common side effect is disruption of bowel or bladder function. Anticonvulsants are more commonly associated with side effects like dizziness, fatigue, and confusion than with disrupted bowel and bladder function. Nonopioid analgesics and nonsteroidal antiinflammatory drugs more commonly result in gastric bleeding, hypertension, and nausea than in disruption of bowel and bladder function.

Which class of pain management drugs may interfere with bowel or bladder function? 1 Anticonvulsants 2 Opioid analgesics 3 Nonopioid analgesics 4 Nonsteroidal antiinflammatory drugs

3 The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain and increase venous capacitance. The other clients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent.

Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp chest pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an elevated blood pressure

4 At greatest risk are older adult clients, opiate-naïve clients, and those with underlying pulmonary disease. The adolescent has two of the three risk factors.

Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Older adult client with chronic pain related to joint immobility 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Opioid-naïve adolescent with an arm fracture and cystic fibrosis

3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine. Phantom limb pain usually subsides after ambulation begins

Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia

2,5,6 The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with acquired immune deficiency syndrome has complex issues that require expert assessment skills. The client pending discharge will need special and detailed instructions.

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication

2,3,6 The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma.

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump 2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

1,3,5,6 These clients should be assigned to an experienced RN because all have acute conditions that require close monitoring for any developing complications. Abdominal cramps secondary to food poisoning is an acute condition; however, the cramping, vomiting and diarrhea are usually selflimiting. The client with chronic back pain would be considered physically stable. Although all clients will benefit from care provided by an experienced RN, the client with abdominal cramps and the client with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse. Test Taking Tip: To determine acuity of clients, use nursing concepts, such as gas exchange and perfusion. Clients 1, 3, 5, and 6 could have potential problems related to perfusion. The client with the chest tube could also have a potential problem related to gas exchange.

Which clients must be assigned to an experienced RN? Select all that apply. 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

A, C, E The safety of PCA is based on the fact that it requires an awake patient to activate the button. The safety is compromised when someone else pushes the button for the patient. A limit on the number of doses per hour or 4-hour intervals may be set. Opioids (morphine PCA) are intended to provide analgesia; drowsiness is an undesirable potential side effect of opioids, and the PCA should only be used for analgesia.

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.) A. Only the patient should push the button. B. Do not use the PCA until the pain is severe. C. The PCA system can set limits to prevent overdoses from occurring. D. Notify the nurse when the button is pushed. E. Do not push the button to go to sleep.

B Sedation is a concern because it may indicate that the patient is experiencing opioid-related side effects. Advancing sedation may indicate that the patient may progress to respiratory depression.

Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95% B. Difficulty arousing the patient C. Respiratory rate of 10 breaths/min D. Pain intensity rating of 5 on a scale of 0 to 10

4 Acetaminophen is considered the best tolerated and safest analgesic used in pain management. Fentanyl and tramadol are opioids, which have the potential for significant side effects and often result in patients building a tolerance to them. Acetylcysteine is not an analgesic; rather, it is used to treat acetaminophen overdose.

Which pain management drug is considered the best tolerated and safest analgesic? 1 Fentanyl 2 Tramadol 3 Acetylcysteine 4 Acetaminophen

2 Inadequate pain management for postsurgical clients can affect quality of life, function, recovery, and postsurgical complication; thus, all the manifestations are examples of negative results. However, venous thromboembolism can lead to pulmonary embolism, and this is an immediate life-threatening concern. The nurse also needs to implement interventions to resolve unsatisfied needs, fear of pain, and hopelessness related to pain and function. Test Taking Tip: Use Maslow's hierarchy to identify priorities in caring for clients. Physiologic needs are the first concern. In this case, venous thromboembolism is the most serious physiologic outcome secondary to inadequate pain management

Which postoperative client is manifesting the most serious negative effect of inadequate pain management? 1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort 2. Develops venous thromboembolism related to immobility caused by pain and discomfort 3. Refuses to participate in physical therapy because of fear of pain caused by exercises 4. Feels depressed about loss of function and hopeless about getting relief from pain