PAIN

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? A. Vital signs B. Self-report of pain C. Severity of the condition D. Nonverbal behavior

Self-report of pain According to evidence-based practice, the most reliable indicator of pain is the client's self-report of pain. A pain intensity scale is a reliable tool to identify the client's pain level.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? A. Obtain an EKG. B. Administer enteric-coated acetaminophen. C. Administer ibuprofen. D. Maintain oxygen saturations greater than or equal to 92%.

Obtain an EKG. The nurse should obtain an EKG to detect heart rhythm abnormalities within 10 min of the client's reported discomfort.

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? SATA 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.

A. Offer the client a back rub. B. Remind the client to use incisional splinting. C. Identify the client's pain level. E. Change the client's position. Nonpharmacological comfort measures improves pain management, also includes repositioning, imagery, and distraction. Holding a pillow against incision when moving, turning, or coughing can help pt w/ self-management of pain. Always determine severity of pain, use standard scale in this case. If the pt is in pain the nurse should implement interventions to help w/ pain before assisting pt to ambulate.

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. Inspecting the site for reduced swelling B. Monitoring the client's pulse rate C. Asking the client to rate the pain D. Having the client perform range-of-motion of the affected arm

Asking the client to rate the pain Pain is a subjective experience. The nurse should encourage the client to quantify the pain on a pain scale before, during, and after cold application to determine its effectiveness.

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? SATA A. Restlessness B. Grimacing C. Moaning D. Clenching E. Drowsiness

Restlessness, grimacing, and clenching are correct. 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 assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse? A. Blood pressure 100/70 mm Hg B. Headache pain rated a 6 on a scale of 0 to 10 C. Respiratory rate 10/min D. Urinary output 30 mL/hr

Respiratory rate 10/min A client who has received spinal anesthesia is at risk for respiratory depression and hypotension. A respiratory rate of 10/min indicates bradypnea and requires immediate intervention.

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? SATA A. Spread the cream over the lateral surface of both forearms. B. Apply to intact skin. C. Apply the medication an hour before the procedure begins. D. Cleanse the skin prior to procedure. E. Use a visual pain rating scale to evaluate effectiveness of the treatment.

Spread the cream over the lateral surface of both forearms is incorrect. The nurse should apply the smallest amount of cream to the smallest area required to reduce the risk for systemic toxicity. Systemic effects of the anesthetic include bradycardia, heart block, and seizures. Apply to intact skin is correct. The nurse should apply cream over intact skin to reduce the risk for systemic toxicity. The nurse should wear gloves while applying the cream to reduce the risk of absorbing the anesthetic. Apply the medication an hour before the procedure begins is correct. The nurse should allow 30 min to 1 hr for the topical analgesic to take effect. Cleanse the skin prior to procedure is correct. Apply the topical analgesic to clean skin to increase absorption. Use a visual pain rating scale to evaluate effectiveness of the treatment is correct. A child's response and understanding of pain depends on the child's age and stage of development. A preschooler might be unable to describe pain due to a limited vocabulary. Use a visual scale (FACES or OUCHER Scale) with faces or colors to assess evaluate the effectiveness of the treatment.

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? A. Increased heart rate B. Decreased respiratory rate. C. Hyperactive bowel sounds D. Decreased blood pressure

Increased heart rate Acute pain stimulates the sympathetic nervous system and can cause an increase in heart rate.

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." The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A. Hypotension B. Numbness C. Shivering D. Reduced blood viscosity

Shivering Shivering is a systemic response to cold therapy as the body attempts to promote heat production

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 pain? A. Vital sign measurement B. The client's self-report of pain severity C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure

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.

A nurse is preparing to administer methlynaltrexone 12 mg subq to a client who has opioid-induced constipation. Available is methlynaltrexone 8mg/0.4 mL. How many mL should the nurse administer?

0.6

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I wish I didn't have to attach the electrodes to my skin." B. "It's unfortunate that I have to be in the hospital for this treatment." C. "I'll need to shave the hair off the skin where I place the electrodes." D. "I hope I don't have to take as many pain pills."

"It's unfortunate that I have to be in the hospital for this treatment." TENS units are portable. The client can use his TENS unit at home or wherever he chooses.

A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse include in the teaching? A. "Use the pain scale to determine if you need to self-administer." B. "Ask a family member to push the patient-control button when the client is sleeping." C. "There is a 30 minute lock-out limit programmed on your PCA pump." D. "Several bolus doses are infused if the button is pushed repeatedly within a 5 to 10 minute timeframe before lock-out."

"Use the pain scale to determine if you need to self-administer." The nurse should instruct the client to use the pain scale to rate his pain level before self-administering a bolus dose. A bolus dose is the amount of medication received when the client self-administers the opioid. The nurse should monitor the client to determine is the bolus dose is too high or low or if the interval is too short or too long.

A nurse is teaching a client who has a new prescription for codeine. Which of the following instructions should the nurse include in the teaching? A. 'You should take the medication on an empty stomach to prevent nausea." B. "You should limit alcohol intake to 12 ounces daily." C. "You should expect to experience diarrhea while taking this medication." D. "You should change positions slowly."

"You should change positions slowly." The client should change positions slowly to avoid the risk of falls. Codeine is an opioid analgesic that causes CNS depression and orthostatic hypotension.

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make? A. "Next time you think he needs more medication, call me and I'll push the button." B. "It's a good idea to help make sure your husband can sleep comfortably." C. "Why do you think your husband needs more medication when he is asleep?" D. "Your husband should decide when more medication is needed."

"Your husband should decide when more medication is needed." The nurse should explain to the client's partner that the client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.

A nurse in the emergency department is preparing to administer naloxone 0.4mg IV bolus to a client who has opioid-induced respiratory depression. Available is naloxone injection 0.2mg/mL. How many mL should the nurse administer per dose?

2

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? A. Determine the time the client last received pain medication. B. Measure the client's vital signs, including temperature. C. Ask the client to rate her pain on a scale from 0 to 10. D. Reposition the client and offer her a back rub.

Ask the client to rate her pain on a scale from 0 to 10. Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.

A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first? A. Administer a bolus of medication. B. Check the display on the PCA pump. C. Obtain an order for another pain medication for breakthrough pain. D. Encourage the client to administer a demand dose.

Check the display on the PCA pump. The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should assess the display on the PCA pump to determine the amount of medication administered. Some clients are fearful of developing an addiction to narcotics and may be reluctant to use the PCA.

A nurse is preparing a client for surgery. Prior to administering the prescribed hydroxyzine, the nurse should explain to the client that the medication is for which of the following indications? SATA A. Controlling emesis B. Diminishing anxiety C. Reducing the amount of narcotics needed for pain relief D. Preventing thrombus formation E. Drying secretions

Controlling emesis Hydroxyzine is an effective antiemetic that may be used to control nausea and vomiting in preoperative and postoperative clients. Diminishing anxiety Hydroxyzine is an effective antianxiety agent that may be used to diminish anxiety in surgical clients, as well as in clients who have moderate anxiety. Reducing the amount of narcotics needed for pain relief Hydroxyzine potentiates the actions of narcotic pain medications; therefore, narcotic requirements may be significantly reduced. Drying secretions Hydroxyzine, an antihistamine, commonly causes drying of the oral mucous membranes.

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.

Determine the location of the pain. The 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.

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? SATA A. Use of analgesics will eventually lead to addiction. B. Each client's expression of pain may be different and individualized. C. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. D. Pain level and pain tolerance can be assessed using a scale from 0 to 10. E. 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 suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications? A. Euphoria B. Rhinorrhea C. Hallucinations D. Dilated pupils

Euphoria (CORRECT) Euphoria is an adverse effect of opioid analgesics and is due to activation of mu receptors. Rhinorrhea Rhinorrhea can occur with opiate withdrawal, but it is not an effect from the medication. Hallucinations Hallucinations are an adverse effect of cannabis. Dilated pupils Constricted pupils are an adverse effect of opioid analgesics.

A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer? A. Epinephrine B. Protamine C. Flumazenil D. Naloxone

Naloxone The nurse should plan to administer naloxone, which is an opiate antagonist that competes with opioids at opiate receptor sites making the opioid ineffective.

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects? A. Diarrhea B. Heartburn C. Hiccups D. Orthostatic hypotension

Orthostatic hypotension The nurse should monitor the client for orthostatic hypotension and encourage the client to rise or change position slowly to decrease the risk for falls.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Administer a local anesthetic.

Remove the catheter and insert another into a different site. It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.

A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an understanding of the teaching? A. "I should only use the device when it's absolutely necessary." B. "I will ask my family to push the dose button when I am asleep." C. "I'll be careful about pushing the button so I don't overdose." D. "I should tell the nurse if I can't control my pain with this device."

"I should tell the nurse if I can't control my pain with this device." PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self-administer pain medication on an as-needed basis The client should notify the nurse if pain control is not achieved. The nurse can initiate a re-evaluation of the client's pain management plan.

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority? A. The client reports weakness of the lower extremities. B. Blood pressure 80/56 mm Hg C. Temperature 38.2°C (100.8°F) D. The client reports perfuse itching.

Blood pressure 80/56 mm Hg When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death.