comfort practice questions

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? a. "I will call for pain medication before the previous dose wears off." b. "I will call for pain medication as my pain starts to increase again." c. "I will wait for you to evaluate my pain before asking for more medication." d. "I will ask for less medication to avoid addiction."

"I will call for pain medication before the previous dose wears off."MY ANSWERThe client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe. "I will call for pain medication as my pain starts to increase again."The client should call for pain medication before the pain starts to increase. "I will wait for you to evaluate my pain before asking for more medication."The client should not wait for the nurse to initiate an evaluation to control postoperative pain. "I will ask for less medication to avoid addiction."The client should receive enough pain medication to control postoperative pain safely.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? Apply the bag for 30 min at a time. Reapply the bag 30 min after removing it. Allow room for some air inside the bag. Place the bag directly on the skin.

Apply the bag for 30 min at a time.The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects. Reapply the bag 30 min after removing it.MY ANSWERAfter removing the ice bag, the nurse should not reapply it any sooner than 1 hr later. Allow room for some air inside the bag.The nurse should squeeze the sides of the bag to remove excess air before putting the cap back on the bag. Air can block the conduction of cold to the injury. Place the bag directly on the skin.The nurse should place a towel, the bag's cover material, or a pillowcase between the ice bag and the client's skin.

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.) Use of analgesics will eventually lead to addiction. Each client's expression of pain may be different and individualized. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. Pain level and pain tolerance can be assessed using a scale from 0 to 10. The client will express the feeling of pain both verbally and nonverbally.

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

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.) a. Offer the client a back rub. b. Remind the client to use incisional splinting. c. Identify the client's pain level. d. Assist the client to ambulate. e. Change the client's position.

Offer the client a back rub is correct. Nonpharmacological comfort measures can improve pain management. Remind the client to use incisional splinting is correct. Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. Identify the client's pain level is correct. The nurse should use a standard scale to determine and document the severity of the client's pain. Change the client's position is correct. Nonpharmacological measures for managing pain include repositioning, imagery, and distraction.

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? a. Set the pad's temperature to 42.2° C (108° F). b. Stop the treatment if the client's skin becomes red. c. Leave the pad in place for at least 40 min. d. Use safety pins to keep the pad in place.

Stop the treatment if the client's skin becomes red. Reactions such as unusual pain or redness are indications for removing the pad and notifying the provider.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client. B. Administer the medication. C. Determine the location of the pain D. Review the effects of the pain medication

Reposition the client. The nurse should reposition the client to help reduce the pain, but there is another action the nurse should take first. Administer the medication.The nurse should administer an analgesic to help reduce the client's pain, but there is another action the nurse should take first. Determine the location of the pain.MY ANSWERThe first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication. Review the effects of the pain medication.The nurse should reinforce teaching about the effects of analgesia so that the client will know what to expect and when to notify the nurse, but there is another action the nurse should take first.

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment? a. Blood pressure b. Apical heart rate c. Respiratory rate d. Temperature

Respiratory rate The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to evaluate the client's respirations. The respiratory rate is especially important because opioid analgesics like morphine can cause respiratory depression.

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority? a. Pupil reaction b. Urine output c. Bowel sounds d. Respiratory rate

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

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.) Restlessness Grimacing Moaning Clenching Drowsiness

Restlessness is correct. Clients who have uncontrolled pain often become restless and anxious in response to the discomfort.Grimacing is correct. Facial movements such as grimacing, tightly closing the eyes, and biting the lower lip are behavioral indicators of pain.Moaning is incorrect. Moaning, groaning, crying, and screaming are vocalizations, not nonverbal behaviors, that indicate pain.Clenching is correct. Clenching the teeth and biting the lower lip are common findings in clients who have pain.Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are common indicators of pain.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan? Vital sign measurementPain can affect vital signs, for example, causing tachycardia, but this is not a reliable indicator of pain for all clients at all times. The client's self-report of pain severityBecause nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly. Visual observation for nonverbal signs of painMY ANSWERNonverbal signs, such as grimacing, can indicate pain, but this is not a reliable indicator of pain for all clients at all times. The nature and invasiveness of the surgical procedureThe nature and invasiveness of a surgical procedure is useful for predicting that the client will experience pain, but it does not indicate how severe a client's pain is at any particular time.

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