nrs 204 weeks 10-14

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? a. Finish the bed bath and then administer the pain medication to the other client b. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. c. Ask the UAP to find out when the last pain medication was given to the client d. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete.

b. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

Pain management in response to human suffering is primary in the nursing role. It is important for the RN to remember that: a. pain is not present if it's not verbalized b. pain is a subjective part of the nursing assessment c. a numerical pain scale is the only valid way to assess pain d. pain is rarely a part of pediatric nursing assessment

b. pain is a subjective part of the nursing assessment

The novice nurse knows that "pain is what the patient says it is". The nurse also keeps in mind that pain occurs in the brain and is highly individualistic, based on past experiences, beliefs, attitudes and meaning. The nurse is demonstrating a good understanding of pain_______________. a. modulation b. perception c. neurotransmitters d. distribution

b. perception

The brain functions as an integral part of the following neurological pain processes: a. swelling at the injury site b. perception, transmission, and modulation c. fainting at the time of injury d. threat, tissue damage, and modality

b. perception, transmission, and modulation

The complex process of biotransformation, which is part of how the human body acts/responds when the drug is introduced to it can be summed up by the process of____________________ a a. toxicity b. pharmokinetics c. drug effectiveness d. drug administration

b. pharmokinetics

What should the nurse do during the evaluation step of the nursing process? a. set the time frame for goals b. revise a plan of care c. determine priorities d. establish outcomes

b. revise a plan of care

A nurse is formulating a plan of care for a client receiving enteral feedings via NG tube. The nurse identified which nursing diagnosis as the highest priority for the patient? a. diarrhea b. risk for aspiration c. deficient fluid volume

b. risk for aspiration

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. antacid b. stimulant laxative c. topical benadryl d. decongestant

b. stimulant laxative

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup a few times last week." b. "I take a baby aspirin every day to prevent strokes." c. "I use acetaminophen (Tylenol) every 4 hours for back pain." d. "I need to take an antacid for indigestion several times a week"

c. "I use acetaminophen (Tylenol) every 4 hours for back pain."

A patient became short of breath and reported sudden chest pain while being transferred from the bed to a chair for the first time after surgery for a fractured hip. The nurse immediately returned the patient to bed, raised the head of the bed and started oxygen at 2 L via nasal cannula. Which step of the nursing process was most important in this scenario? a. planning b. assessing c. evaluating d. diagnosing

c. evaluating

Acetaminophen is an example of the _______________ name of the drug that Health Care providers typically utilize when prescribing. a. chemical b. molecular c. generic d. trade

c. generic

The nurse plans to advise the patient to avoid which food(s) before ingesting an enteric-coated medication? (select all that apply) a. bananas b. baked potatoes c. ice cream d. broiled fish e. fried chicken

c. ice cream e. fried chicken

The '8 rights' safety habits for drug administration is integral to nursing practice, and must be incorporated each time a medication is administered to the patient. In practice, this also includes:____ a. Alerting and educating patient to potential side effects of the drug/ evaluate for any drug interactions, and following up with a patient 30 minutes after drug administration to evaluate effectiveness. b. When educating the patient on a new drug, avoid using the generic name of the drug, only utilize the brand name c. During the busy change of shift, let the oncoming RN administer the drug within 30 minutes of the prescribed time. d. Advising the patients regarding the cost of drugs, and encouraging them to purchase the medications 'in bulk' instead of in smaller quantities for a more cost-effective alternative

a. Alerting and educating patient to potential side effects of the drug/ evaluate for any drug interactions, and following up with a patient 30 minutes after drug administration to evaluate effectiveness.

A patient is found unresponsive with a suspected opiate overdose. Emergency naloxone is going to be administered. What does the nurse need to keep in mind regarding naloxone? (select all that apply) a. Naloxone is a widely-endorsed opiate antagonist, blocking the effects of opiates on the brain and restoring breathing b. Naloxone's antidote properties last for over 2 hours after administration c. Naloxone's effects can work within 2-3 minutes d. Naloxone can be administered via IM, IV or Intranasal e. Naloxone is a schedule II addictive substance

a. Naloxone is a widely-endorsed opiate antagonist, blocking the effects of opiates on the brain and restoring breathing c. Naloxone's effects can work within 2-3 minutes d. Naloxone can be administered via IM, IV or Intranasal

The components of pain modulation are further described in the following statements: (select all that apply) a. Pain modulation originates in the brain/spinal cord, as released substances that inhibit brain signal transmission. b. Neurotransmitters such as dopamine and serotonin, and hormones including oxytocin and endorphins are natural pain modulators c. Food, music, laughter, massage, dance, meditation are biochemical pain modulators d. Pain modulators increase the pain signal in the brain to a manageable level e. Pain modulation has been known to occur on the battlefield, when an injured soldier does not 'feel pain' in the midst of the intense violence

a. Pain modulation originates in the brain/spinal cord, as released substances that inhibit brain signal transmission. b. Neurotransmitters such as dopamine and serotonin, and hormones including oxytocin and endorphins are natural pain modulators c. Food, music, laughter, massage, dance, meditation are biochemical pain modulators e. Pain modulation has been known to occur on the battlefield, when an injured soldier does not 'feel pain' in the midst of the intense violence

Which statements accurately portray the 'Drug Schedules' of the 1970 Controlled Substances Act? (select all that apply) a. Schedule I drugs are illegal, and unregulated, with high abuse potential b. Schedule IV medications require prescription,(like valium) with some abuse potential c. Pseudoephedrine (Sudafed) is highly addictive and is now classified as schedule 1 d. Schedule III Opiates (like Morphine and oxycodone) are unregulated, but have less abuse potential than schedule I e. drugs bought over the counter are 100% safe and effective

a. Schedule I drugs are illegal, and unregulated, with high abuse potential b. Schedule IV medications require prescription,(like valium) with some abuse potential

A nurse is taking care of a patient who had a right below-the knee amputation two days ago. Patient reports intermittent burning pain in his nonexistent right ankle. What are some ways that the nurse might support the patient in his suffering? (select all that apply) a. The nurse understands that phantom limb pain is a unique and real phenomenon of neuropathic pain. b. The patient suffering with phantom limb pain generally suffers physical and psychological distress c. The nurse educates patients that this syndrome is usually very short-lived d. The nurse displays a non-judgemental attitude while patient describes painful symptoms

a. The nurse understands that phantom limb pain is a unique and real phenomenon of neuropathic pain. b. The patient suffering with phantom limb pain generally suffers physical and psychological distress d. The nurse displays a non-judgemental attitude while patient describes painful symptoms

When the nurse administers a drug via IV, important factors to be aware of include: (select all that apply) a. There is a greater risk of potential toxicity because this route of drug administration bypasses absorption and is inserted directly into the bloodstream for distribution b. The nurse must adhere to aseptic technique with drug administration c. For most drugs, the dose in IV form is usually a larger dose compared to the dose in oral route form. d. A medication via the IV route has the longest half-life compared to the other routes of administration e. The IV method of drug administration can facilitate the most rapid desired effects of the medication

a. There is a greater risk of potential toxicity because this route of drug administration bypasses absorption and is inserted directly into the bloodstream for distribution b. The nurse must adhere to aseptic technique with drug administration e. The IV method of drug administration can facilitate the most rapid desired effects of the medication

Which statement is related to the concept that is central to the nursing process? a. it is dynamic rather than static b. it focuses on the role of the nurse c. it moves from simple to complex d. it is based on the patient's medical problem

a. it is dynamic rather than static

The comprehensive nursing pain assessment includes questions regarding: (select all that apply) a. location b. intensity c. absence d. duration e. quality

a. location b. intensity d. duration e. quality

During clinical judgement, a nurse.. (select all that apply) a. may make the decision to take or not to take action b. should avoid modifying standard approaches c. may use or modify standard approaches d. can improvise entirely new approaches e. reviews the standards of nursing care

a. may make the decision to take or not to take action c. may use or modify standard approaches d. can improvise entirely new approaches

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? a. notify the health care provider b. administer the prescribed medication c. call and ask the operating room team to perform surgery as soon as possible d. reposition the client and apply a heating pad on their abdomen

a. notify the health care provider

A nurse notices things about the patient in the context of (select all that apply) a. nurse's background b. nurse's knowledge of the patient c. nurse's experience d. environment e. patient's psychological state

a. nurse's background b. nurse's knowledge of the patient c. nurse's experience d. environment

The nurse will question the health care provider if a drug with a half-life of more than 24 hours is ordered to be given more than how often? a. once daily b. every other day c. twice weekly d. once weekly

a. once daily

When an administered drug, such as acetaminophen, reaches a therapeutic range of action, reaching sites of destination through the blood brain barrier, this process is a part of the concept of:________________ a. pharmacodynamics b. pharmacokinetics c. metabolism d. minimum effective concentration

a. pharmacodynamics

The routes of drug administration that avoid the 'first pass' hepatic effects include: (select all that apply) a. sublingual b. oral c. transdermal d. lower rectal suppositories e. inhalation

a. sublingual c. transdermal d. lower rectal suppositories e. inhalation

Factors which effect a drug's volume of distribution include: (select all that apply) a. the age of the patient b. presence of disease c. the route of drug administration d. extent of drug-plasma protein binding e. blood flow to tissues

a. the age of the patient b. presence of disease d. extent of drug-plasma protein binding e. blood flow to tissues

A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? a. fever b. nausea c. diaphoresis d. abdominal cramping

c. diaphoresis

For the first time, a nurse is taking care of a patient with the diagnosis of diabetic neuropathy. Both of the patient's legs below the knees have redness, discoloration, and both feet are swollen, with the beginning signs of a skin ulcer on the R heel. What statement best reflects a nurse's understanding of the disease process and patient safety? a. The symptoms show that the patient must be managing their blood sugars at the optimal level. b. The patient is at risk for increased injuries and infections because the disease process damages peripheral nerves and inhibits the patient from detecting pain c. The patient's condition is acute and reversible with the right treatment. The patient just needs to exercise more d. The patient's new regimen will include keeping both feet elevated at all times.

b. The patient is at risk for increased injuries and infections because the disease process damages peripheral nerves and inhibits the patient from detecting pain

The nurse is explaining drug action to a nursing student. Which statement made by the nurse is correct? a, route of administration has no impact on effect of drugs b. a drug not bound to protein is an active drug in the system c. most receptors are found under the cell membrane d. toxic effects can result if the trough level is low

b. a drug not bound to protein is an active drug in the system

A nurse manager of a medical-surgical unit returns to work after being on vacation for a week. It is the beginning of the shift, and the nurse manager is faced with several activities that need attention. Which activity will the nurse manager attend to first? a. a crash cart needs checking b. client assignments for the day c. a phone message that indicates a charge nurse is ill and will not be reporting to work d. a stack of mail from the education department and administrative services

b. client assignments for the day

A patient is receiving vancomycin IV for treatment of a serious bone infection. The nurse knows that vancomycin has a very narrow therapeutic range. A 'peak and trough' blood level is ordered for the dose the nurse is next administering. Which priority action should be taken by the nurse? a. ask the patient if he has any diarrhea b. determine if the trough level has been drawn c. monitor the blood culture and sensitivity report d. administer per schedule, and be on alert for signs of toxicity

b. determine if the trough level has been drawn

Which of the following signs or symptoms in an opioid-naïve 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 12 breaths/minute d. pain intensity of 5/10

b. difficulty arousing the patient

Some disadvantages involving the oral route of drug administration include: (select all that apply) a. drugs taken orally are the least economical b. drugs taken orally may cause emesis c. drugs taken orally are always metabolized by the gastrointestinal flora d. drugs taken orally may by destroyed by gastric acidity e. drugs taken orally may be inconsistently absorbed due to the presence of food

b. drugs taken orally may cause emesis d. drugs taken orally may be destroyed by gastric acidity e. drugs taken orally may be inconsistently absorbed due to the presence of food

When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient's pain? a. how long have you had this pain b. how would you describe your pain c. how much medication do you take for pain d. how many times a day do you medicate for pain

b. how would you describe your pain

In clinical judgement, there is a understanding that nursing care is not (select best answer) a. always effective b. linear c. cyclical d. standardized

b. linear

A family member asks you, "Why can't you give more medicine? He is still having a lot of pain." What is your best response? a. the doctor ordered the medicine to be given every 4 hours b. "If the medication is given too frequently he could suffer ill effects." c. "Please tell him that I will be right there to check on him." d. "Let's wait about 30-40 minutes. If there is no relief I'll call the doctor."

c. "Please tell him that I will be right there to check on him."

A nurse is taking care of a patient diagnosed with a right hip fracture due to a fall on the icy sidewalk. The patient is wincing and cannot bear weight on her right leg. She is prescribed narcotics to help ease the intense pain prior to surgery. What might be an appropriate nursing diagnosis for this patient? a. Risk for skin breakdown related to decreased activity status. b. Ineffective tissue perfusion r/t hip injury c. Acute pain related to right hip injury as evidenced by wincing and inability to bear weight on right leg

c. Acute pain related to right hip injury as evidenced by wincing and inability to bear weight on right leg

A general rule of thumb for nurses when helping pregnant patients make informed choices about medication is:____________ a. Tell the patient to avoid medications at all costs. Most medications are in pregnancy categories C, D and X, which harm the fetus. Pregnancy is the time to 'tough it out' with headaches and backaches b. Inform the patient that the growing baby is protected by the placenta 'blanket of armor', so, it is very rare that any medications will affect the baby. c. Research the risks of any prescribed medications with the patient, in particular, utilizing the Pregnancy and Lactation Labelling rule of 2015. d. Educate the patient that Schedule III and Schedule IV drugs will have little to no adverse effects on the baby.

c. Research the risks of any prescribed medications with the patient, in particular, utilizing the Pregnancy and Lactation Labelling rule of 2015.

In situations in which it is critical to raise a patient's drug plasma level quickly, what should the nurse be prepared to administer? a. therapeutic blood level b. a drug that will penetrate the blood brain barrier c. a loading dose d. a protein inhibitor drug

c. a loading dose

The route of drug administration affects predominantly the process of:___________________ a. access b. excretion c. absorption d. half-life

c. absorption

A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks how these techniques work. The nurse's reply is based on the information that these strategies: a. slow the release of neurotransmitter chemicals b. augment the potency effect of narcotics c. impact the cognitive and affective components of pain perception d. prevent transmission of nociceptive stimuli to the cortex

c. impact the cognitive and affective components of pain perception

The two most important sites for drug elimination include_______________ a. pulmonary and liver b. liver and gastrointestinal tract c. kidney and liver d. skin and kidney

c. kidney and liver

A nurse is looking for ______ that are consistent with previous experiences and uses that information to guide care (select best answer) a. details b. connections c. patterns d. conclusions

c. patterns

Family members are encouraging your client to "tough it out" rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family's wishes. Priority nursing interventions for this client should target which dimension of pain? a. sensory b. affective c. sociocultural d. cognitive

c. sociocultural

An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient? a. working in multiple health care settings b. learning good communication skills c. spending time establishing relationships with patients d. relying on evidence in practice

c. spending time establishing relationships with patients

A home health nurse is taking care of patient TK with end-stage liver disease. A family member visiting informed the nurse that the patient complained of a headache earlier that morning, and so she went ahead and gave the patient 500 mg of Tylenol. What is the best response by the nurse? a. is the headache gone now b. yikes that is a no-no are you aware of how tylenol is metabolized c. thank you for letting me know. For the future, please avoid giving TK Tylenol for pain. Tylenol is processed by the liver, and may cause additional liver damage in a patient with liver disease d. as the nurse for the patient, i'm the only one authorized to give medications

c. thank you for letting me know. For the future, please avoid giving TK Tylenol for pain. Tylenol is processed by the liver, and may cause additional liver damage in a patient with liver disease

Important factors to remember regarding the functioning of the neurological system of pain is: a. acute pain receptors process pain differently than chronic pain receptors b. neurological pain cannot be treated with different modalities-only the strongest opiates c. the peripheral system transmits pain signaling and the central system processes and reacts to pain signals d. analgesia is impaired when pathology of the somatosensory system exists

c. the peripheral system transmits pain signaling and the central system processes and reacts to pain signals

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. a client scheduled for a chest x ray b. a client requiring daily dressing changes c. a postoperative client preparing for discharge d. a client receiving nasal oxygen who had difficulty breathing during the previous shift

d. a client receiving nasal oxygen who had difficulty breathing during the previous shift

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the meds. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. this is an example of: a. creativity b. fairness c. clinical strategizing d. applying ethical criteria

d. applying ethical criteria

A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? a. providing range of motion exercises to the wrists b. removing the restraints periodically per agency guidelines c. applying lotion to the skin under the restraint d. assessing color, sensation, and pulses distal to the restraints

d. assessing color, sensation, and pulses distal to the restraints

_______ is the process of assembling information to make sense of it (select best answer) a. organizing b. clustering c. deducing d. interpreting

d. interpreting

During the pain assessment for a patient with a cancer diagnosis, the patient describes the pain as 'sharp, burning shooting arrows' down his leg. Medication thus far has provided little relief. The nurse understands that these symptoms may be classified as: a. acute nonsocomial pain b. tumor transduction pain c. transmission pain d. neuropathic pain

d. neuropathic pain

Pain that is 'aching, cramping, throbbing' occurring as a result of tissue damage (injury, surgery, sudden loss of blood flow) is classified as: a. transducer pain b. chronic pain c. psychomotor pain d. nociceptive pain

d. nociceptive pain