Chapter 36: Comfort and Pain Management
A nurse is assessing an adult client with back pain. The client is unable to speak the dominant language. Which pain scale is most appropriate for the nurse to use in assessing the client's pain?
0 to 10 numeric rating scale Explanation: The 0 to 10 numeric rating scale can be used in adults and children (>9 years old) who are able to use numbers to rate the intensity of their pain. The PAINAD scale is used in clients whose dementia is so advanced that they cannot verbally communicate. The FLACC scale is used in infants and children (2 months-7 years) who are unable to validate the presence of, or quantify, the severity of pain. The Payen behavioral pain scale is used with intubated, critically ill clients, including measurement of bodily indicators of pain and tolerance of intubation.
A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation. What would be the sedation score for this client?
3 Explanation: The sedation score for this client is 3. A score of 1 is given to a client who is awake and alert, 2 is given to a client who is slightly drowsy but easily aroused, and 4 describes a client who is somnolent, with minimal or no response to physical stimulation.
A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action?
Administer naloxone Explanation: Naloxone is an opioid antagonist that reverses the respiratory depressant effects of opioids. If stimulation is ineffective in arousing a client using opioids, naloxone can be used. When the client is alert and the respiratory rate is greater than 9 breaths/min, the opioids may be resumed. A code blue is not appropriate, as there is no indication that the client is without pulse or respiration. However, being prepared for this action is necessary. The nurse will contact the health care provider but first needs to take action to prevent further deterioration of the client's condition. The family must be notified but the most pressing matter is the care of the client.
When performing a pain assessment on a client, the nurse observes that the client guards his arm, which was fractured in a car accident, and he refuses to move out of his chair. The nurse notes this reaction as what type of pain response?
Behavioral Explanation: Behavioral (voluntary) responses would include moving away from painful stimuli, grimacing, moaning, crying, restlessness, protecting the painful area, and refusing to move the limb. Physiologic (involuntary) responses would include increased blood pressure, increased pulse and respiratory rates, pupil dilation, muscle tension and rigidity, pallor (due to peripheral vasoconstriction), increased adrenaline output, and increased blood glucose. Psychological responses would include exaggerated weeping and restlessness, withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, and powerlessness.
A client reports a dull, aching pain to his right flank where he was struck during a football game one week ago. What is responsible for the transmission of such pain?
C-fibers Explanation: Stimulation of C-fibers, which are slow conducting fibers, is responsible for the dull and poorly localized pain persistent after the injury. A-delta fibers give rise to bright, sharp, and well-localized pain that is immediately associated with the injury. The frontal lobe of the brain is not directly involved in the physiology of the pain response. The spinal dorsal complex horn is the site where complex processing of messages occurs.
The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention?
Closing the client's room door to reduce unnecessary noises Explanation: A noisy environment, even talking, can be a source of stimuli that causes discomfort; therefore, closing the client's room door is a way to adjust the environment to make it quieter. Assisting the client to change positions or smoothing out wrinkles in the bed linen is implementation of physical adjustment techniques to promote comfort. Offering the client a book or music is using a technique of distraction to help the client not focus on the discomfort.
The demonstration provided by the nurse is directed at helping the postsurgical client manage what type of pain?
Deep somatic Explanation: Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, muscles and nerves. The nurse is demonstrating splinting, which will help minimize muscular pain caused by coughing and deep breathing after abdominal surgery. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Neuropathic pain caused by a lesion or disease of the peripheral or central nerves. Cutaneous or superficial pain usually involves the skin or subcutaneous tissue.
The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply.
Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken. Explanation: The nurse will provide instructions about the medication prescribed for pain relief. This medication is an opioid, and extra precautions are required. The client is not to drive a vehicle while taking an opioid due to slowed reflexes and decreased cognitive thinking. The client is not to breast-feed her infant without checking with her primary care provider. The opioid may be absorbed into the breast milk and fed to the infant, which may adversely affect the infant. The client is to keep a diary about her pain experiences, which includes level of pain and time the medication was taken. This provides a more accurate documentation of the pain experience and prevents overdosage from taking the medication too frequently. The client is not to drink alcohol. Alcohol will depress the central nervous system when taken with an opioid and may lead to respiratory failure. The client may smoke, but someone will need to be present (for safety reasons) since the client may fall asleep due to the opioid. It does not matter whether it is day or night. The medication is not better absorbed when taken on an empty stomach. The client takes the pain medication with food, since nausea is a frequent side effect when the opioid is taken on an empty stomach.
While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?
Document the finding. Explanation: The nurse should document this finding after completion of the back massage and client care and report it to the health care provider. The nurse would also position the client to remove any pressure from that area. The nurse should not apply a warm compress or massage the reddened area.
How should the nurse position the head of the bed for a client receiving epidural opioids?
Elevated 30 degrees Explanation: The nurse should position the head of the bed so that it is elevated 30 degrees unless contraindicated. Elevation of the client's head minimizes upward migration of the opioid in the spinal cord, thereby decreasing the risk for respiratory depression. The Trendelenburg position is when the feet are higher than the head. Reverse Trendelenburg position or supine position is when the head is higher than the feet.
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?
Endorphins Explanation: Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that certain measures, such as skin stimulation and relaxation techniques, release endorphins. Serotonin is an important chemical and neurotransmitter in the human body. It is believed that serotonin helps regulate mood and social behavior, appetite and digestion, sleep, memory, and sexual desire and function. Melatonin is a hormone that is produced by the pineal gland in humans and animals and regulates sleep and wakefulness. Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers.
The client is a new admission who reports lower right quadrant abdominal pain. The client is scheduled for an emergency appendectomy. What question(s) will the nurse ask the client in relation to the pain? Select all that apply.
How do you rate your pain on a scale of 0 to 10? Does anything make the pain worse? How would you describe the pain? When did your pain begin? What medication have you taken to relieve the pain? Explanation: All of these questions are appropriate for a pain assessment. They are part of a comprehensive pain assessment, which is to be performed on the client's admission to a clinical facility. The nurse wants to quantify the client's pain as well as wants to qualify the client's pain by asking for a description of the pain in the client's own words. The nurse asks about the onset, which is when the pain began. It is important to know what medications the client has taken for pain relief. For this client, it is extremely important, because the client is going for emergency surgery. These medications could affect the client's outcome for the surgery.
A 54-year-old man is recovering from an outbreak of Herpes zoster on his left chest. He tells the nurse that even his shirt touching him causes a horrible pain on the left side of the chest. What term would best describe the client's pain?
Hyperalgesia Explanation: Herpes zoster is a common cause of hyperalgesia.
A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?
PRN order Explanation: A PRN order is one that is given to a client on an "as needed" basis.
A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action?
Start with the lowest intensity and gradually increase it to the appropriate level. Explanation: After applying the electrodes, the nurse should turn on the unit and adjust the intensity setting to the lowest intensity and determine if the client can feel a tingling, burning, or buzzing sensation. The nurse should then adjust the intensity to the prescribed amount or the setting most comfortable for the client. Skin should be clean before applying the electrodes, but it is unnecessary to use disinfectant. Analgesia may or may not be necessary before a TENS session.
The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate?
The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. Explanation: The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min or has unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache. No other medications should be administered; a peripheral IV line should already be in place. Resistance should not be felt when removing an epidural catheter.
The nurse is conducting a pain assessment with an older adult client. The nurse notices that the client grimaces when the nurse asks the client to lean forward. The client, however, rates pain as 3 out of 10 on the numerical pain rating scale. The nurse recognizes that the client may be reporting pain inaccurately for which reason(s)? Select all that apply.
The client is concerned about being perceived as weak or bothersome. The client believes that pain is a normal part of the aging process. The client has a fear of becoming addicted to pain medications. The client is doubtful that any interventions will be helpful. Explanation: Older adults may not report pain for several reasons, such as not wanting to be perceived as a nuisance or a complainer, believing that pain is expected with aging or is an indicator of weakness, fearing addiction to pain medication, or misperceiving that nothing can be done to alleviate the pain. By recognizing and exploring possible reasons for the incongruence between the objective and subjective assessment data, the nurse can improve the quality of the client's pain management. The nurse will not assume that the client has a high tolerance for pain. Because the client is showing non-verbal signs of significant pain (facial grimace), the nurse must probe further to determine the source of the client's inaccurate reporting of the pain. Doing so can lead to further education about pain management and better client outcomes.
A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?
The dose that is delivered when the client activates the machine is preset. Explanation: PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdoses.
At 1930 the client reports experiencing neuropathic pain in the legs. The client has a history of neuropathic pain following chemotherapy. The client describes the pain as burning and rates the pain as a 7 on the pain scale of 1 to 10. Based on the client's medication orders (above), which medication would the nurse administer to the client for a report of pain?
acetaminophen/codeine 1 tablet Explanation: The nurse would administer the acetaminophen/codeine 1 tablet dose for pain rated as a 7. Because the pain is not rated as severe (8 to 10), the nurse would not administer acetaminophen/codeine 2 tablets. Acetaminophen is prescribed for mild pain. The client has rated the pain as moderate. It would not be appropriate for the nurse to undermedicate the client and to administer solely acetaminophen. Amitriptyline is an adjuvant medication. It is usually not used as a first line treatment for pain. It is prescribed to prevent pain and to decrease the dose of drugs primarily used for pain relief.
When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should:
actively solicit information about the client's pain level. Explanation: Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Health care providers need to recognize the client's cultural beliefs and not impose their own judgments.
A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:
biofeedback. Explanation: Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. The unit transforms the data into a visual display, and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief.
A client comes to the facility reporting acute pain. When assessing the client, the nurse understands that moderate, superficial acute pain can result in which sympathetic physiologic response(s)? Select all that apply.
increased blood pressure increased pulse increased respiratory rate Explanation: Sympathetic physiologic responses to moderate superficial acute pain can include increased blood pressure, pulse, and respiratory rate.
A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?
modulation Explanation: The client is in the modulation phase of pain, during which the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience. Transduction phase refers to the conversion of chemical information at the cellular level into electrical impulses that move toward the spinal cord. In transmission phase, the stimuli move from the peripheral nervous system toward the brain. The perception phase occurs when the pain threshold is reached.
A client with recurrent episodes of migraine headaches tells the nurse, "I am not comfortable taking medication for my pain." Which pain relief technique(s) can the nurse teach the client to implement at home? Select all that apply.
relaxation massage meditation biofeedback Explanation: Relaxation, meditation, massage, and biofeedback are pain relief techniques that the nurse can teach the client to implement at home. Relaxation techniques involve a combination of a quiet environment, a comfortable position, a passive attitude, and a focus of concentration. Meditation is a technique in which the person focuses on a single thought or sound. In biofeedback, the client learns voluntary control over autonomic functions such as heart rate, hand temperature, and muscle tension. Massage is a pain relief technique used to relax muscles and reduce tension. For migraines, the client can self-implement massage or ask a family member or friend to provide the massage. Hypnosis is a cognitive pain relief technique that blocks the awareness of pain through suggestions or by substituting another feeling for pain. Hypnosis cannot be implemented at the home; this techniques requires a professional to perform the action.
Who is the authority on the presence and extent of pain experienced by a client?
the client Explanation: The only one who can be a real authority on whether, and how, an individual is experiencing pain is that individual. A surgeon is responsible for pain associated with surgery, but the client is the one that communicates the experience to the nurse. An anesthesiologist is a health care provider who provides anesthesia during the surgical process. They are responsible for the care of the client during surgery.
A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?
the client's pain based on a pain rating Explanation: The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.
A nurse is caring for a client whose injured cells are releasing chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?
transduction Explanation: The client is going through the transduction phase, which is the first phase of pain in which injured cells release chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Transmission is the phase during which stimuli move from the peripheral nervous system toward the brain. Perception occurs when the pain threshold is reached. Modulation is the last phase of pain impulse transmission, during which the brain interacts with the spinal nerves to alter the pain experience.
A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?
visceral pain Explanation: Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.
A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:
visceral pain. Explanation: The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.
A sudden blow to the head results in pain that is transmitted by which type of fibers?
A-delta Explanation: A-delta fibers give rise to bright, sharp, well-localized pain that is immediately associated with injury.
The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?
Acknowledge the pain as the client reports it and administer pain medication as prescribed. Explanation: Pain is subjective and the nurse must acknowledge pain as the client reports it. Observing the client's behavior is not an appropriate nursing intervention, as pain is a self-reported finding. Taking the client's vital signs would help in administering pain medications, as pain medicine can lower a client's blood pressure and heart rate. The nurse will not report the client to the health care provider; this is making assumptions about the client.
Which medical client is most likely to be experiencing diffuse pain?
A client with shingles affecting her entire torso Explanation: Diffuse pain is pain that covers a large area and, usually, the client is unable to point to a specific area without moving the hand over a large surface, such as the client's entire torso. Pain related to appendicitis, a stab wound, or strep throat is more likely to be localized and sharp.
The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain?
"How long have you experienced this pain?" Explanation: Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset. Asking if the client has had this pain before reflects patterns. Asking the client to rate pain on a 1-10 scale reflects intensity.
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as
"Acute pain tends to increase during the day and is called a routine pain response" Explanation: Acute pain occurs abruptly after an injury or disease and persists until healing occurs. Acute pain also may be associated with anxiety and fear. Acute pain consistently increases at night and during wound care, ambulation, coughing, and deep breathing.
The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?
"I should only take medication when my pain is intense." Explanation: PCA pumps allow the client to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense. The pump is programmed with a lockout period that limits the chance of clients overmedicating themselves.
Evelyn is a 90-year-old woman who just returned from the operating room to your medical unit. She is otherwise healthy and has a history of some mild arthritis. As you examine Evelyn, you know that all of the following are signs of pain EXCEPT which?
Elevated kidney function Explanation: Kidney function would be temporarily suppressed by acute pain.
The nurse recognizes which statement is true of chronic pain?
It may cause depression in clients. Explanation: Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because of the unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation.
Which client populations are at high risk for inadequate pain management? Select all that apply.
Neonates and infants Young children Clients with dementia Older adults with chronic pain Explanation: Client populations who are not able to communicate pain effectively are at highest risk for inadequate pain management. These clients are the neonates, infants, young children, and clients with dementia. Adults older than age 65 experience pain more frequently than do younger adults and endure moderate to severe pain for twice as long as younger adults. However, many see pain in older adults as part of the normal aging process and it is therefore undertreated.
A nurse is giving a client a back massage. Which actions should the nurse perform? Select all that apply.
Observe the client's skin over bony prominences. Warm the lubricant in the palm of the hand. Keep hands in contact with the client's skin at all times. Explanation: The nurse should observe the client's skin for reddened or open areas, paying particular attention to the skin over bony prominences. The nurse should warm the lubricant in the palm of the hand, as cold lotion causes chilling and discomfort. The nurse should keep hands in contact with the client's skin at all times, as a firm stroke with continuous contact promotes relaxation. The bed should be raised to the nurse's elbow height, not hip height. The nurse should use light, gliding strokes (effleurage) to apply lotion, not heavy percussive ones, as effleurage relaxes the client and lessens tension. The nurse should complete the massage with additional long, stroking movements that eventually become lighter in pressure, not alternating grasping and compression motions, as the former are soothing and promote relaxation.
Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?
Pain assessment may require multiple methods in order to ensure accurate pain data. Explanation: It is often necessary to use more than one technique for pain assessment in children. Though their neurologic system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all clients above a certain age; the assessment tool should reflect the client's specific circumstances, abilities, and development.
The nurse is caring for a client receiving epidural opioids . What side effects of the medication should the nurse assess for? Select all that apply.
Pruritis Urinary retention Nausea Infection Explanation: The nurse should assess for side effects that include, hypotension, pruritus, urinary retention, nausea and vomiting, infection, and respiratory depression.
A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?
Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. Explanation: The sedation score for this client is 3. This requires collaboration with the primary care provider to decrease the analgesic dose. Naloxone is not likely necessary, nor is it appropriate to completely discontinue the client's pain control.
Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?
Respiratory Explanation: The priority assessment for the nurse caring for a client with a PCA pump is respiratory, with particular attention to the respiratory rate and pattern. Too much opioid or a displaced catheter may allow the medication to have a depressant effect on the brainstem center, causing life-threatening respiratory depression. The cardiac system can be affect by a opioid PCA by decreasing the blood pressure and heart rate as the pain decreases. It is expected but not the priority. The neuromuscular and peripheral vascular system are not affected by the PCA.
The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?
They bind to opioid receptor sites throughout the CNS. Explanation: When endogenous opioids are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the central nervous system (CNS), blocking the release or production of pain-transmitting substances.
A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:
in the postoperative stage with occasional pain. Explanation: A PRN (as needed) medication would be most appropriate for a client in the postoperative stage with occasional pain. A client in the early postoperative period would benefit from the dosage of pain medication with around the clock dosing. A client experiencing chronic pain would benefit from the dosage of pain medication with around the clock dosing. A client experiencing acute pain would benefit from the dosage of pain medication with around the clock dosing.
After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?
3 Explanation: The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows: 1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.
A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse?
Administer the medication if respiratory rate is > 9. Explanation: The nurse can safely administer the new pain medication when the client's respiratory rate is greater than 9. Opioids can cause respiratory depression. Therefore, this is important to monitor before administering the opioid. Blood pressure and heart rate are slightly elevated due to the client experiencing pain. These vital signs are stable to administer the opioid.
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?
Administration of 0.4 mg of naloxone Explanation: The client is experiencing impending respiratory arrest due to the effect of the medication and this should be reversed immediately prior to arrest. This is the priority action and will correct the respiratory depression immediately. CPR is not indicated at this time, because the client is not in full arrest. Placing the client in the supine position may decrease respirations further.
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?
Assess for medication prescription for breakthrough pain. Explanation: Breakthrough pain is a temporary flare-up of moderate to severe pain that occurs even when the client is taking pain medication around the clock. It can occur before the next dose of analgesic is due (end of dose pain). It is treated most effectively with supplemental doses of a short-acting opioid taken on an "as needed basis." Therefore, the nurse should check for a prescription for breakthrough pain medication. Telling the client that he or she has to wait is not a therapeutic action by the nurse. Administering the next dose of pain medication is a violation of nursing practice and does not follow the standard of care. The nurse needs to assess for the therapeutic effects of the pain medication and not opioid addiction.
The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment?
Assess for nonverbal cues to pain Explanation: The nurse must not make assumptions about how a client experiences or interprets pain; the nurse should acknowledge the pain as the client reports it. At the same time, the nurse will fully assess the client and document any nonverbal clues to pain observed. Contacting the pain clinic should be an intervention at the time of discharge. Requesting a lower dose of pain medication is not appropriate. Discussing the observations with the client may allow for communication regarding the client's care, but the nurse should acknowledge the pain level as the client reports it, as pain is subjective.
The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment?
Respiratory status, oxygen saturation, pain, and sedation level Explanation: Respiratory status, oxygen saturation, pain, and sedation level are the best description of the priority of the hourly assessments for this client. The priority concern for this client is the risk of respiratory depression because of the use of analgesia; therefore, the priority assessments during the first 12 hours of epidural therapy include assessing the client's vital signs, respiratory status, pain status, sedation level, oxygen saturation at least once per hour during the first 12 hours of therapy. If there are no complications after 12 hours, the assessments should continue every 2 hours and then decrease per facility policy. Airway, breathing, and circulation are the top priorities in the care of any client, and in this client, breathing is a concern because of the risk of respiratory depression from the epidural analgesia. Although important, the other options do not best describe the priority assessments because the main concern, the risk of respiratory depression, is not the focus of the other options.
An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?
The client exhibits restless, uncharacteristic behavior after receiving the drug. Explanation: Paradoxical effects of hypnotics involve a stimulating effect or mental changes. Tolerance, somnolence, and respiratory depression are not indicative of paradoxical effects.
A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?
"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression." Explanation: The rationale for keeping the head of the bed elevated 30 degrees is that this position helps to minimize the upward migration of the opioid in the spinal cord, thereby minimizing the risk of respiratory depression. The nurse does not keep the head of the bed elevated to decrease the risk of migraines as migraines are not a common problem with epidural analgesia. Positioning of the client does not increase the effectiveness of the medication. Positioning also does not prevent accidental dislodgement of the catheter; this is accomplished by a secure dressing and taping the tubing so that it is not pulled.
A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating?
1 Explanation: Using a sedation scale, 1 indicates that the client is alert and awake. S is used to document that the client is sleeping but easy to arouse. 2 is used to denote that the client is slightly drowsy but easy to arouse. 3 is used to denote that the client is frequently drowsy, arousable but drifts off to sleep during a conversation.
The health care provider has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?
confused to time and place Explanation: Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion in a client would lead the nurse to question the client's ability to correctly use the PCA.
The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?
reviewing and revising the pain management treatment plan Explanation: The nurse's focal point should be on reviewing and revising the pain management treatment plan presently in place. The client is status-post bowel resection, so administering a placebo is not the correction option, and could be ethically wrong. The nurse would possibly do a depression assessment, but if the client is reporting constant pain, the pain management plan must be reviewed and revised. The question does not address if the client is taking pain medications, so the option addressing beginning pain medications before the pain is too severe is not correct.
