Case Study 10

After reviewing Ms.J (end stage multiple myeloma) med list, the nurse is most likely to question scheduled dose of which med? 1) Naltrexone 2) Fentayl 3) Morphine 4) Acetaminophen

1

For Ms.R (RA), which discharge topic is the most important to emphasize to prevent a major post-surgical complication? 1) Activity and movement limitations for the affected shoulder 2) Continuation of pain meds as prescribed 3) Possibility of repeat surgery for ongoing disease changes 4) Expected post-surgical symptoms, such as localized pain

1

Mr.O (tibia-fibula fracture) is a risk for compartment syndrome because of the cast. Which pain assessment finding most strongly suggest compartment syndrome? 1) Pain on passive motion 2) Sudden increase in pain 3) Intense discomfort r/t an 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 patient? 1) Constipation 2) Respiratory depression 3) N/V 4) Sedation

1

Which non-pharmacologic intervention for pain management is the most appropriate for Mr.L (kidney stone)? 1) avoid over-hydration or under-hydration 2) Gently massage the lower back 3) Darken the room to encourage rest and sleep 4) Apply an ice pack to the kidney area

1

Based on the info. that the nurse received during hand-off report for Mr.L (kidney stone), what is the priority concept to consider in planning interventions for this patient? 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 (who has bacterial pneumonia and is HIV+), what is the *priority* concept to consider in planning care for this patient? 1) Pain 2) Gas exchange 3) Immunity 4) Cellular regulation

2

Mr.A (bacterial pneumonia) has a single lumen peripherally inserted central catheter, and he has the following scheduled medications and IV solutions that need to be given now: vancomycin 1.5 g in 250 mL of 5% dextrose over 90 min, levofloxacin 750 mg in 150mL of normal saline over 90 min, 5% dextrose and 0.45% saline 100 mL with 20 mEq of potassium at 125mL/hr and an IV bolus does of morphine 3mg. What is the 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 med and solution 3) Give the bolus dose of morphine because it will take the least about of time 4) Obtain an order to establish an additional peripheral IV site

2

Mr.H (hernia repair) is asking for pain med, and the HCP had ordered 10 mg of immediate-release oxycodone as needed. The pharmacy has stocked 5 mg tablets of controlled-release oxycodone in the med cabinet. What is the priority action? 1) Call the HCP for clarification of the original prescription. 2) Call the pharmacy and obtain the immediate release form of the drug 3) Ask the patient if the immediate or controlled release action is preferred 4) Give two of the 5 mg tablets to achieve the correct does

2

Mr.H is given a dose of pain med. One hour later, he is anxious and appears uncomfortable and he asks "whats the matter? Is something wrong? Im still hurting." What action should be taken *first*? 1) Call the HCP for a change in med or dose 2) Initiate NPO in case surgery is needed 3) Check for bladder distention and last voiding 4) Reassure the patient that the hernia is not recurring

3

Mr.L (kidney stone) calls for pain medication. He describes the pain caused by his kidney stones as excruciating. He is crying, diaphoretic, and pacing around the room. What is the *priority* action? 1) Instruct Mr.L to do deep breathing exercises 2) Remind Mr.L to use the PCA pump when he has pain 3) Give Mr.L an PRN IV bolus dose as ordered 4) Call the HCP immediately to report pain and other symptoms

3

Mr.L (kidney stone) reports that the pain has decreased compared with earlier, but now he is having other symptoms. Which symptoms is of greatest concern? 1) Painless hematuria with small clots 2) Dull pain that radiated into the genitalia 3) Absence of pain but scant UO 4) Sensation of urinary urgency

3

Mr.O (tibia-fibula fracture) reports an increasing pain in the right abdomen. On physical examination, there are hyperactive BS, a tense abdomen with guarding, and exquisite tenderness with gentle palpation. What is the *priority* action? 1) Give a PRN pain med 2) Notify the HCP of findings 3) Take a complete set of VS 4) Assist him to change position

3

Ms.J (end-stage multiple myeloma) 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 2) Doxepin 3) Lorazepam 4) Dicyclomine

3

Which non-pharmacologic pain measure to help Ms. R (RA) relieve her early morning stiffness should be delegated to the UAP? 1) Assisting Mr.R to get in a bathtub full of warm water 2) Sharing some relaxation techniques with Ms.R 3) Assisting Ms.R to take a warm shower 4) Evaluating the effectiveness of paraffin therapy

3

One of the staff members is talking about Mr.A who has bacterial pnemonia, saying "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 the best response to this comment? 1) All patients have a right to care regardless of race or creed 2) I'll take Mr.A; I dont 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

Which morning tasks can be delegated to the UAP? Select all that apply. 1) Assisting Mr.R, who has RA with morning care 2) Reinforcing to Mr.L, who has a kidney stone, the need to save urine for straining 3) Preparing Mr.H's room for his return from the OR for hernia repair 4) Reporting on the condition of MR.O's skin resulting from his motorcycle accident 5) Getting coffee for Ms.J's (end-stage multiple myeloma) family 6) Checking on the pulse ox reading for Mr. A, who has bacterial pneumonia

1, 2, 3, 5

Which of the six patients can be assigned to the new RN? Select all that apply. 1) Ms. R (rheumatoid 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 positive)

1, 2, 4

Which end of the shift task can be delegated to the UAP? Select all that apply. 1) Emptying Ms.J trash can and placing items within reach 2) Checking Mr.A lines for moisture and soiling and changing as needed 3) Asking Mr.L if he needs a dose of pain meds before shift change 4) Assisting Ms. R to change position in bed to relieve pressure on joints 5) Ensuring Mr.O leg is elevated and evaluating comfort 6) Emptying Mr.A urinal and recording the output

1, 2, 4, 6

Which tasks r/t pain management can be delegated to the UAP? Select all that apply. 1) Reporting on grimacing seen in unresponsive patients 2) Asking about he locations, quality, and radiation of pain 3) Reminding patients to report pain as necessary 4) Observing for relief after medication is given 5) Asking patients directly, "are you having pain?" 6) Determining if position change relieves pain

1, 3, 5

Mr.H (hernia repair) says, "I have several friends who became addicted to drugs, and it totally ruined their lives. Im afraid to take any kind of addictive drugs" What is the nurse's *best* response? 1) your HCP prescribes types of opiods that do not cause addiction 2) you will be given opioids for a very short time, and addiction is unlikely 3) your friends probably had addictive personalities; you don't need to worry 4) if you become addicted, the HCP will refer you to a drug rehab program

2

Mr.H returns from the OR after a hernia repair. He says that he is "afraid to walk because it will make the pain really bad" What does the nurse explain as being the *best* option? 1) Pain med every 4hr if he needed or want it 2) Med 30 to 40 min before ambulation or dressing changes 3) Around the clock pain med even if he has no report of pain 4) Talking to the HCP for reassurance about the treatment plan

2

Ms. J (end stage multiple myeloma) son tells the nurse, "My mom is having trouble breathing, and she is having a lot of pain!" On assessment, Ms.J demonstrates rapid shallow breathing and reports pain over the right lateral ribs that increase with movement and breathing. What is the priority action? 1) Take VS with pulse ox reading and inform the HCP 2) Apply oxygen and raise the HOB if patient is not hypotensive 3) Obtain an order to start an IV and to give a bolus dose of morphine 4) Be calm, stay with the patient, and encourage purse lip breathing

2

Ms. R (RA) tells the nurse, "I really dread doing the postoperative exercises". She seems fearful and grimaces when the nurse suggest that pain medication can be given before the exercise begin. Which member of the health care team would the nurse consult *first*? 1) Psychiatric clincal nurse specialist to evaluate fears 2) OT to review the exercise therapy 3) Pharmacist to verify efficacy of prescribed pain med 4) Surgeon to review the expected progress of healing

2

The UAP reports that the new nurse is under-medicating the patients. What is the best way for the team leader 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 of the nurses patients

2

The new nurse tells the team leader that she cannot find and documentation that shows the time of Mr.L (kidney stone) last does of pain med. What action should occur *first*? 1) help the new nurse look at the chart and medication admin. record 2) tell the new nurse to ask the night nurse before she leaves 3) speak to the night shift nurse about the documentation 4) Have the new nurse ask Mr.L when he last had medication

2

During the shift, the following events occur at the same time. Prioritize the oder for addressing these problems. 1) Mr.L is calling out loudly about right sided flank pain caused by his kidney stone 2) Mr.O who was in a motorcycle accident is calling "the pump tipped over, and its 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 Mr.A (bacterial pneumonia) pain management can be delegated to the UAP? Select all that apply 1) Clean the TENS unit 2) Notify the nurse about the patient's request for pain med 3) Reinforce the use of a pillow to splint when coughing 4) Observe for actions that increase fatigue or anxiety 5) Suggest that relatives bring personal comfort items 6) Assist the patient to change position every 2 hr

2, 3, 6

Later in the shift, Mr.A (bacterial pneumonia )reports "the chest pain is gone, but my back really hurts a lot. I need more morphine" Based on the ethical principal of non-maleficence, what is the nurses priority action? 1) Believe Mr.A subjective report of pain and give pain med as ordered 2) Contact the HCP for an increase in dosage because Mr.A appears to need a higher dose 3) Consider history of addiction and chronic pain, respiratory status, and time of last does 4) Offer non-pharmaceutical measures. such as position change or distraction

3

At the end of the shift, the opioid count shows that two tablets of oxycodone are unaccounted for. The tea, leader has spoken to all of the nurses and pharmacist who had access to the med cabinet during the shift, but no one will admit to removing those tablets. What should the team leader do. Select all that apply 1) Inform the staff that no one can leave until the matter is resolved 2) Fill out an incidednt report and include facts about findings and actions 3) interview all of the patients who have orders for oxycodone 4) Discuss the matter with the unit manager and review potential problems of the current system 5) Review available records of access and medication retrieval for the past 24 hours 6) Ask the staff if they saw any other people who may have accessed the cabinet during the shift

2, 4, 5, 6

For Mr.O, in addition to pain medication, which action will help the most to relieve pain associated with the tibia fibula fracture caused by his motorcycle accident? 1) Instruct him to periodically moves his toes 2) Use diversional therapy 3) Elevate the injured leg above the heart 4) Place the patient in a high Fowler position

3

It is the end of the shift, and the new nurse is trying to give pain meds to one patient, provide comfort measures for another patient, and redo pain assessment on all her patients. Her documentation is incomplete. What should the team leader 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 to prioritize and delegate the tasks 4) Ask someone from the oncoming shift to help her

3

The team leader is giving the end of shift report about Ms.R (RA) to the oncoming nurse. Place the following info in the correct order. 1) she has shoulder pain (4 out of 10) and was reluctant to move around 2) Do you have any questions for me 3) Ms.R is a 55 yo women 4) She had shoulder arthroplasty 3 days ago 5) She received a PRN dose of acetaminophen with codeine, and her pain is now 1 of 10 6) the physical therapist must speak to Mr.R daughter so page hime when she arrives

3, 4, 1, 5, 6, 2

Mr. A (bacterial pneumonia) reports left-sided anterior chest pain. What is the priority action? 1) Obtain an order for an electrocardiogram and continuous telemetry monitoring 2) Auscultate the lung fields and compare to baseline assessments 3) Give a PRN pain medication and reevaluate after 30 min 4) Ask him to describe the pain and measure all the VS

4

Ms. J son repeatedly insist that Ms.J is not getting enough pain med. He threatens to sue. The team leader has used therapeutic communication skills with the son and advocated for the patient with the HCP. The HCP says "I'll be in tomorrow. Just tell the son to chill out" What is the best action? 1) call another HCP 2) continue to use the current order 3) Advise the son to call the HCP 4) Notify the unit manager

4

The nurse reinforces teaching about the purpose and correct use of the PCA with MR.O (tibia-fibula fracture) and his mother. Both express an understanding and willingness to comply. When is the best time for Mr.O to activate the PCA to receive a does of pain med? 1) Whenever pain is a 5 on scale of 0 to 10, with 10 being the worst pain imaginable 2) 30 min after waking up in the morning and 30 min before bedtime 3) As soon as the lockout time expires; if pain is still present, even if it is mild 4) 10 min before a painful procedure such as a dressing change of PT

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 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 nurse to the unity manager for failure to safeguard the patient 2) Explain the purpose and function of the PCA delivery system to the mother 3) Give the night nurse written information about the dangers of possible overdoes 4) First talk to the night nurse about the PCA procedure, then talk to the mother

4

The team leader is preparing to give Mr.L (kidney stone) pain med, but the IV site is infiltrated, so the nurse informs him that the IV catheter will have to be reinserted. He yells, "Whats 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 medication 2) This is not my fault, but if you will just give me a couple of minutes, 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 you IV right now

4

The team leader is 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 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 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 type of activities did you used to do?

4

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 (rheumatoid 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 positive)

6, 3, 2, 1, 5, 4