EAQ Pain
A client is in skin traction while awaiting surgery for repair of a fractured femur. The client reports leg discomfort and asks the nurse to release the traction. Which is the nurse's best initial response? 1 "I can't because the weights are needed to keep the bone aligned." 2 "I will remove half of the weights and notify your health care provider." 3 "I'll get your prescribed pain medication to help relieve your discomfort." 4 "I have to follow the health care provider's directions, and releasing weights is not prescribed."
"I can't because the weights are needed to keep the bone aligned." The response, "I can't because the weights are needed to keep the bone aligned," explains why the traction may not be released; a continuous pull must be maintained. Reducing the weight requires a health care provider's prescription; removing half the weights will not maintain the bone in alignment. The response, "I'll get your prescribed pain medication to help relieve your discomfort," ignores the client's request to release the traction; further assessment is needed. Although "I have to follow the health care provider's directions, and releasing weights is not prescribed" is a true statement, it does not provide the rationale as to why the weights should not be released.
A blood transfusion of packed cells has been prescribed for a client. The transfusion started five minutes ago and the client is complaining of chest pain and nausea, having difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 99.2 degrees, and the client seems less alert. The nurse suspects: 1 Urticarial reaction. 2 Hemolytic reaction. 3 Circulatory overload. 4 Anaphylactic reaction.
2 Hemolytic reaction. Chest pain, nausea, having difficulty breathing, and chills are signs of hemolytic reaction, which occurs with incompatible blood. Later come symptoms of shock and loss of consciousness. This type of reaction occurs within minutes of starting the infusion. Urticarial reactions are minor allergic reactions that typically have hives. Circulatory overload typically would occur with rapid infusion and would raise the blood pressure. An anaphylactic reaction would cause respiratory or cardiac collapse
After flushing a client's left forearm saline lock with normal saline, the client begins to complain about a painful and burning sensation at the insertion site. What is the most appropriate action for the nurse to take? 1 Document the findings per protocol and reassess the site in eight hours. 2 Remove the angiocatheter and saline lock and restart the IV in another site. 3 Notify the health care provider (HCP) as soon as possible. 4 Flush the angiocatheter and saline lock again with sterile water
2 Remove the angiocatheter and saline lock and restart the IV in another site.
A client being treated for uncontrolled hypertension and chest pain calls out to the nurse and reports he or she is having a nose bleed. Upon entry to the client's room, the nurse immediately applies pressure. Which action should the nurse take next? 1 Add humidity to the client's oxygen prescribed at 2 L/minute via nasal cannula. 2 Assess the client for further injuries indicative of a possible fall. 3 Auscultate the client's blood pressure. 4 Assess the client's pulse rate.
3 Auscultate the client's blood pressure. Nose bleeds in adults often are indicative of hypertension in adults. While oxygen can dry out the mucus membranes in the nose, and assessing the client for further injuries is plausible, the nurse's first action should be to assess blood pressure, especially because the client was admitted for uncontrolled hypertension. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or responses that appear to be degrading
A 14-year-old girl in whom scoliosis has been diagnosed undergoes spinal fusion. On the first postoperative day her face is red, she is rigid, and she is crying because she is in pain. She has prescriptions for morphine sulfate for severe pain and an acetaminophen-codeine compound for moderate pain. What information should influence the nurse's choice of analgesic? 1 One dose of morphine may be given, but the drug should be restricted thereafter because it is addictive. 2 Adolescents tend to exaggerate their discomfort, particularly when they are immobilized by surgery or injury. 3 Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic. 4 The acetaminophen-codeine compound is preferred because morphine can cause respiratory depression or respiratory arrest.
3 Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic. Spinal fusion causes considerable pain for several days and requires a strong analgesic. The first postoperative day is too early to begin weaning the client from opiates. Adolescents are no more prone to exaggerating their discomfort than clients in any other age group. A more potent analgesic, such as morphine, is needed, and the prescribed dosage should not cause respiratory problems.
A nurse is caring for a 2½-year-old child who is expressing pain. What is the most reliable indicator of this child's pain? 1 Crying and sobbing 2 Changes in behavior 3 Verbal exclamations of pain 4 Changes in pulse and respiratory rate
Changes in behavior Although there are several indicators of pain in children, a change in behavior is the one that occurs most often. Crying is not a valid indicator of pain; there is more than one cause for crying, including pain, separation, fear, and unhappiness. Children often hide their pain; they may perceive it as punishment, or they may fear the treatment that will be given to relieve the pain. Vital signs often do not change, even if the child is in pain
A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient care analgesia (PCA) pump running with a basal rate of hydromorphone (Dilaudid). The nurse assesses the client's vital signs as BP 90/60 mm Hg, heart rate 96 beats/min, and respiratory rate of 10 breaths/min. What next action should the nurse take? a) Document the findings and reassess in 2 hours. b) Turn off the pump and give naloxone (Narcan) intravenous push med (IVP) per protocol. c) Assess the client's pain level on a 10-point scale. d) Call the rapid response team
b) Turn off the pump and give naloxone (Narcan) intravenous push med (IVP) per protocol.
A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that a client has a prescription for morphine 2 mg intravenously (IV) every 3 hours for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain on a level 8 on a pain scale of 1 to 10. What is the first thing the covering nurse should do? a)Determine when the pain medication was last given. b)Verify the pain medication prescription in the clinical record c)Employ nonpharmacological measures initially to relieve the pain. d)Explain that the primary nurse will be back from lunch in a few minutes.
b)Verify the pain medication prescription in the clinical record Before administering any medication for the first time the nurse must verify the accuracy of the prescription. The prescription as it appears in the medication administration record is verified against the prescription in the client's medical record. This ensures that the prescription was transcribed accurately. Checking when the pain medication was last given is done after the prescription is verified. Nonpharmacological measures are used for mild to moderate pain, not pain associated with recent major abdominal surgery. The client's pain must be immediately addressed. The covering nurse is capable of verifying the pain medication prescription and administering it safely at the correct time