Lacharity Chapter 1
1. You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client.
1. Ans: 4 Have a conference with the nurses responsible for the care of this client. As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, prioritization
10. For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function with your continued support and supervision? 1. Therapeutic touch 2. Application of heat and cold 3. Meditation 4. Transcutaneous electrical nerve stimulation (TENS)
10. Ans: 2. Application of heat and cold Application of heat and cold is a standard therapy with guidelines for safe use and predictable outcomes; therefore, the LPN/LVN could implement and educate the client about this therapy under the supervision of an RN. Therapeutic touch requires additional training and practice. Meditation is not acceptable to all clients, and an assessment of spiritual beliefs should be conducted. TENS is usually applied by a physical therapist. Focus: Delegation
11. A client received "as needed" (PRN) morphine, lorazepam (Ativan), and cyclobenzaprine (Flexeril). The UAP reports that the client has a respiratory rate of 10/min. What is the priority action? 1. Call the physician to obtain an order for naloxone (Narcan). 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20/min. 4. Double-check the drug order to see what the client should have received.
11. Ans: 2. Assess the client's responsiveness and respiratory status. First assess the client. The UAP has correctly reported her findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on your assessment findings, the other options may also be appropriate. Focus: Prioritization
12. Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Elderly client with chronic pain who has a hip fracture 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Child with an arm fracture and cystic fibrosis
12. Ans: 4. Child with an arm fracture and cystic fibrosis At greatest risk are elderly clients, opiate-naive clients, and those with underlying pulmonary disease. The child has two of the three risk factors. Focus: Prioritization
13. A client is crying and grimacing but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 4. Seek family assistance in resolving this problem.
13. Ans: 1. Encourage expression of fears and past experiences. This client has strong beliefs and emotions related to the issue of the sibling's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, but it should be kept in mind that their beliefs about drug addiction may be similar to those of the client. Focus: Prioritization
14. A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps
14. Ans: 3. Diaphoresis Diaphoresis is one of the early signs that occur between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal. Focus: Prioritization
15. In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress
15. Ans: 1. Assisting the client with preparation of a sitz bath The UAP is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities. Focus: Delegation
16. The physician has ordered a placebo for a client with chronic pain. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? 1. Prepare the medication and hand it to the physician. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice.
16. Ans: 4. Contact the charge nurse for advice. Administering placebos is generally considered unethical. Consult the charge nurse as a resource person who can help you clarify the situation and locate and review the hospital policy. If the physician is insistent, suggest that he or she could give the placebo. (Note: Use "could," not "should" when talking to the physician. This provides a small opportunity to rethink the decision. "Should" is more commanding and elicits a more defensive response.) While following your own ethical code is correct, you must ensure that the client is not abandoned and that care continues. Focus: Prioritization
17. For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Look at the MAR and chart to note the time of the last dose of analgesic and the client's response. 4. Give the maximum PRN dose within the minimum time frame for relief.
17. Ans: 2. Obtain baseline behavioral indicators from family members. Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns. Focus: Prioritization
18. You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today.
18. Ans: 5, 3, 1, 2, 4 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today. 3. Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. 4. Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. All of the clients are in relatively stable condition. The client with the pneumothorax has priority, because chest tubes can leak or become dislodged or blocked. Lung sounds and respiratory effort should be evaluated. The woman who will be undergoing diagnostic testing should be assessed and medicated before she leaves for the procedure. In a client with meningitis, a headache is not an unexpected complaint, but neurologic status and pain should be assessed. The report of postoperative pain is expected, but this client is getting reasonable relief most of the time. Caring for and assessing the client with Alzheimer disease is likely to be very time consuming; checking on her last prevents delaying care for all the others. Focus: Prioritization
19. On the first day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the first action you should take? 1. Deliver the bolus dose per standing order. 2. Contact the physician to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity.
19. Ans: 4. Assess the pain for location, quality, and intensity. Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps. Focus: Prioritization
2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. "Where is the pain located, and does it radiate to other parts of your body?" 2. "How would you describe the pain, and how is it affecting you?" 3. "What do you believe about pain medication and drug addiction?" 4. "How is the pain affecting your activity level and your ability to function?" 5. "What information do you need about pain, healing, and addiction?"
2. Ans: 3 "What do you believe about pain medication and drug addiction?" Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization
20. The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? 1. Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format 2. Giving the ordered dose of Narcan and evaluating the response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered
20. Ans: 4. Applying oxygen per nasal cannula as ordered The LPN/LVN is well trained to administer oxygen per nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the physician for ongoing treatment and therapy. Focus: Delegation
21. What is the best way to schedule medication for a client with constant pain? 1. PRN at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around the clock
21. Ans: 4. Around the clock If the pain is constant, the best schedule is around the clock, to provide steady analgesia and pain control. The other options may actually require higher dosages to achieve control. Focus: Prioritization
22. Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? (Select all that apply.) 1. Client who needs preoperative teaching for the use of a PCA pump 2. Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications
22. Ans: 2, 3, 6 2. Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 6. Client with arthritis who needs scheduled pain medications and heat applications The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma. Focus: Assignment
23. You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3° F (38° C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR format. 1. "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 2. "He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse." 3. "I have tried to make him comfortable and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." 4. "Would you like to give me an order for any laboratory tests or additional therapies at this time?" 5. "Dr. S, this is Nurse J. I'm calling about Mr. D, who is reporting severe abdominal pain."
23. Ans: 5, 2, 1, 3, 4 5. "Dr. S, this is Nurse J. I'm calling about Mr. D, who is reporting severe abdominal pain." 2. "He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse." 1. "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 3. "I have tried to make him comfortable and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." 4. "Would you like to give me an order for any laboratory tests or additional therapies at this time?" Using the SBAR format, the nurse first identifies himself or herself, gives the client's name, and describes the current situation. Next, relevant background information, such as the client's diagnosis, medications, and laboratory data, is stated. The assessment includes both client assessment data that are of concern and the nurse's analysis of the situation. Finally, the nurse makes a recommendation indicating what action he or she thinks is needed. Focus: Prioritization
24. Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with human immunodeficiency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically-implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent PRN pain medication
24. Ans: 2, 5, 6 2. Client on the second postoperative day who needs pain medication before dressing changes 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent PRN pain medication The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with HIV infection has complex complaints that require expert assessment skills. The client pending discharge will need special and detailed instructions. Focus: Assignment
25. A client's family member says to you, "He needs more pain medicine. He is still having a lot of pain." What is your best response? 1. "The physician ordered the medicine to be given every 4 hours." 2. "If the medication is given too frequently, he could experience ill effects." 3. "Please tell him that I will be right there to check on him." 4. "Let's wait about 30 to 40 minutes. If there is no relief, I'll call the physician."
25. Ans: 3. "Please tell him that I will be right there to check on him." Directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next. Focus: Prioritization
26. Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, "None of these doctors has done anything to help." Which client statement concerns you the most? 1. "I twisted my back last night, and now the pain is a lot worse." 2. "I'm so sick of this pain. I think I'm going to find a way to end it." 3. "Occasionally I buy pain killers from a guy in my neighborhood." 4. "I'm going to sue you and the doctor; you aren't doing anything for me."
26. Ans: 2. "I'm so sick of this pain. I think I'm going to find a way to end it." This statement is a veiled suicide threat, and clients with pain disorder and depression have a high risk for suicide. New injuries must be evaluated, but this type of complaint is not uncommon for clients with pain disorder. Risk for substance abuse is very high and should eventually be addressed. He can threaten to sue, but current circumstances do not support his case. Focus: Prioritization
27. A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced UAP states that she received training in Foley catheter insertion at a previous job. What task can be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the Foley catheter, once you ascertain that she knows sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a urine specimen
27. Ans: 4. Measuring the urine output after the catheter is inserted and obtaining a urine specimen Measuring output and obtaining a specimen are within the scope of practice of the UAP. Insertion of the Foley catheter in this client should be done by the RN, because clients with obstruction and retention are usually very difficult to catheterize, and the nurse must evaluate the pain response during the procedure. The UAP's knowledge of sterile technique is not the issue for this particular client. Focus: Delegation
28. You are caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is an order to discontinue the PCA-delivered morphine and to start oral pain medication. The client begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." What is the best response? 1. "Let me stop the pump and we can try oral pain medication to see if it relieves the pain." 2. "I realize that you are scared of the pain, but we must try to wean you off the pump." 3. "Show me where your pain is and describe how it feels compared to yesterday." 4. "Let me take your vital signs, and then I will call the physician and explain your concerns."
28. Ans: 3. "Show me where your pain is and describe how it feels compared to yesterday." Assessing the pain is the priority in this acute care setting, because there is a risk of infection or hemorrhage. The other options might be appropriate based on your assessment findings. Focus: Prioritization
29. You are caring for a young client with diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose level is 650 mg/dL, but she refuses insulin; however, she wants the pain medication. What is the best action? 1. Notify the charge nurse and obtain an order for a transfer to intensive care. 2. Explain that insulin is a priority and inform the health care provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin.
29. Ans: 2 Explain that insulin is a priority and inform the health care provider. Explain that insulin is a priority because life-threatening ketoacidosis is already in progress. If she is already aware of the dangers of an elevated blood glucose level, then her refusal suggests ongoing suicidal intent and the provider should be notified so that steps can be taken to override her refusal (potentially a court order). A blood glucose level of over 600 mg/dL is typically a criterion for transfer to intensive care, but making arrangements for transfer does not address the priority issue, which is refusal of therapy. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of possible ongoing suicidal intent. Focus: Prioritization
3. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)
3. Ans: 1. Gabapentin (Neurontin) Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant nedication. Focus: Prioritization
4. Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia
4. Ans: 3. A client with progressive pancreatic cancer Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization
5. As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in charting.
5. Ans: 4. Give praise for correctly charting the dose and time and discuss the deficits in charting. In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision, delegation
6. Which clients must be assigned to an experienced RN? (Select all that apply.) 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis
6. Ans:: 1, 3, 5, 6 1. Client who was in an automobile crash and sustained multiple injuries 3. Client who has returned from surgery and has a chest tube in place 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis These clients should be assigned to an experienced RN because all have acute conditions that require close monitoring for any developing complications. Abdominal cramps secondary to food poisoning is an acute condition; however, the cramping, along with vomiting and diarrhea, are usually self-limiting. The client with chronic back pain would be considered physically stable. While all clients will benefit from care provided by an experienced RN, the client with abdominal cramps and the client with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse. Focus: Assignment
7. In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. The client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed.
7. Ans: 3. The client's perception of pain must be accepted. The client must be believed, and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to the other options in developing the treatment plan. Focus: Prioritization
8. Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp chest pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an elevated blood pressure
8. Ans: 3. Client who is having an acute myocardial infarction with severe chest pain The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain by increasing venous capacitance. Other clients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent. Focus: Prioritization
9. When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the client is pain free. 3. Titrate downward to prevent toxicity. 4. Titrate to a dosage that is adequate to meet the client's subjective needs.
9. Ans: 1. Titrate to the smallest dose that provides relief with the fewest side effects. The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs. Focus: Prioritization