Module 2: Pain

Which mode of medication administration is preferred for a client with deep partial-thickness burns who is receiving an opioid for pain management? Oral Rectal Intravenous Intramuscular

Intravenous Rationale: The intravenous route provides for the quickest onset of action of the opioid; pain relief occurs almost immediately. Nausea, vomiting, and paralytic ileus may occur postburn, making oral medications impractical. The rectal route does not provide uniform absorption; also, relief of pain will be delayed. With the intramuscular route, medication may be sequestered in the tissues, and with fluid shifts it takes time for the medication to take effect.

After undergoing minor surgery, a postoperative child has recovered from anesthesia. Which observations alert the nurse the child may be ready for discharge? Select all that apply. One, some, or all responses may be correct. Vital signs are stable. Temperature is 101°F/38°C Pain rate is at baseline level. The child is alert and oriented. Oxygen saturation is 75% on room air.

Vital signs are stable. Pain rate is at baseline level. The child is alert and oriented. Rationale: The child can be discharged only if the vital signs are consistent at least 30 minutes after the administration of the last dose of the anesthetic medication. The child's temperature should be lower than 101°F/38°C. The child should be alert and oriented. The pain rate should be minimal. The oxygen saturation should be at least 95% on room air for at least 30 minutes after the administration of the last dose.

Which nursing interventions would the nurse implement for a child undergoing treatment with opioid analgesics? Select all that apply. One, some, or all responses may be correct. Assessing the child's level of pain Administering oral medications with meals or snacks Assessing the child's verbal and nonverbal behaviors Documenting the child's age, weight, and height before treatment Monitoring and documenting the child's vital signs before the start of therapy

Assessing the child's level of pain Administering oral medications with meals or snacks Assessing the child's verbal and nonverbal behaviors Documenting the child's age, weight, and height before treatment Rationale: Assessing the child's level of pain is very important for a child undergoing treatment with opioid analgesics. This can be done with the use of the Ouch scale. Oral medications may be given with meals to prevent or ease gastric discomfort. A careful assessment of verbal and nonverbal behaviors help the nurse understand the child's feelings, including intensity of pain. The child's age, weight, and height are important data in the calculation of pediatric dosages. Vital signs should be checked before, during, and after the administration of opioid analgesics.

The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy? Promotes analgesia and circulation Numbs the nerves and dilates the blood vessels Promotes circulation and reduces muscle spasms Causes local vasoconstriction, preventing edema and muscle spasms

Causes local vasoconstriction, preventing edema and muscle spasms Rationale: Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

Which factor would the nurse recognize as a cause of neck pain in a client? Headache Poor posture Low body weight Sedentary lifestyle

Poor posture Rationale: Poor posture may affect the nerves innervating the neck, thereby causing pain in the neck. Headache may be associated with neck pain, but it does not precipitate neck pain. Low body weight and sedentary lifestyle may cause osteoporosis.

In which time frame would the nurse advise a client with a long leg cast for a fractured bone to take the prescribed as-needed oxycodone? Just as a last resort Before going to sleep As the pain becomes intense When the discomfort begins

When the discomfort begins Rationale: Pain is most effectively relieved when an analgesic is administered at the onset of pain, before it becomes intense; this prevents a pain cycle from occurring. Analgesics are less effective if administered when pain is at its peak. Before going to sleep, it may or may not be necessary; the medication should be taken when the client begins to feel uncomfortable within the parameters specified by the health care provider's prescription. Analgesics are less effective if administered when pain is at its peak.

A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? Maintain the settings programmed by the health care provider. Turn the machine on several times a day for 10 to 20 minutes. Adjust the dial on the unit until the client states that the pain is relieved. Apply the color-coded electrodes on the client where they are most comfortable

Adjust the dial on the unit until the client states that the pain is relieved. Rationale: The voltage or current is adjusted on the basis of the degree of pain relief experienced by the client. Maintaining the settings programmed by the health care provider may provide too little or too much stimulation to achieve the desired response. Pain-suppressor TENS units must be turned on several times a day for 10 to 20 minutes, not the conventional units. The electrodes should be applied either on the painful area or immediately below or above the area.

According to the nursing process, which action would the nurse take after administering pain medication to a postoperative client? Administer nonpharmacological comfort measures. Inform the health care provider of the nursing action. Create a care plan that addresses the client's pain level. Determine whether the pain medicine relieved the client's pain.

Determine whether the pain medicine relieved the client's pain. Rationale: After implementation of a nursing action (administration of pain medication), the nurse must evaluate the intervention's effectiveness. Administering nonpharmacological comfort measures is a different intervention and does not occur as a result of the pain medication. The nurse does not need to inform the provider of the nursing action. The nurse creates a plan of care before administering the pain medication, not after.

A school-age child with end-stage cancer has a continuous infusion of morphine to manage their pain. Breakthrough pain occurs and a fentanyl 'lollipop ' is prescribed. Which instruction would the nurse give the child regarding the use of the lollipop when pain occurs? 'Chew it and then swallow every 4 hours.' 'Suck on it for half an hour every 6 hours.' 'Hold it in your cheek only until the pain is relieved.' 'Place it in your mouth and suck on it until it dissolves.'

'Hold it in your cheek only until the pain is relieved.' Rationale: The fentanyl lozenge is absorbed through the buccal mucosa; once the pain is relieved the lozenge should be removed and kept until it is needed again. The lozenge should be sucked, not chewed. There is no specific length of time to suck on the lozenge. The lozenge should not remain in the mouth once the pain is relieved.

After interacting with a client, the nurse thinks the client is in the prodromal phase of a migraine. Which statements made by the client led the nurse to reach this conclusion? Select all that apply. One, some, or all responses may be correct. 'I feel drowsy all the time.' 'I feel severe pain over my ear. I feel a throbbing pain in my head.' 'I feel confused at this point in time.' 'I feel weakness in the left side of my body.'

'I feel drowsy all the time.' 'I feel confused at this point in time.' 'I feel weakness in the left side of my body.' Rationale: A migraine is a clinical syndrome characterized by recurrent episodic attacks of head pain. The first phase of a migraine headache is called the prodromal phase. In the prodromal phase, a variety of neurological changes are seen. These include drowsiness, acute confusion, vertigo, numbness and tingling of lips or tongue, aphasia, and unilateral weakness. Severe pain over the ear is pain in the templar region and is the second phase of a migraine headache. Throbbing pain in the head occurs in the third phase of a migraine

Which property would the nurse understands that the medication is being used primarily for when aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis? Analgesic Antipyretic Anti-inflammatory Antiplatelet

Anti-inflammatory Rationale: The anti-inflammatory action of aspirin reduces joint inflammation. It can relieve pain and prevent abnormal clotting; however, although these effects can be beneficial, these are not the primary reasons that it is prescribed for rheumatoid arthritis. Aspirin reduces fever, but this is not the rationale for prescribing it for clients with rheumatoid arthritis.

Which is the most reliable indicator of a 2.5-year-old child's pain? Crying and sobbing Changes in behavior Verbal exclamations of pain Changes in pulse and respiratory rate

Changes in behavior Rationale: 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 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

Which physiological response will occur if a client being treated for myocardial infarction experiences the intended therapeutic effect of morphine? Increased respiratory rate Decreased workload of the heart Dilation of coronary arteries Diminished metabolites within the ischemic heart muscle

Decreased workload of the heart Rationale: Morphine reduces pain and anxiety. This limits the response of the sympathetic nervous system, ultimately decreasing cardiac preload and the workload of the heart. Reduced respiratory rate is a side effect of morphine; it is not the intended therapeutic effect for a client being treated for myocardial infarction. Morphine causes peripheral vasodilation but not coronary artery dilation. Decreasing metabolites within the ischemic heart muscle is not the action of morphine.

Assessment findings of a client who is admitted to the emergency department include cramping pain in the left lower quadrant, weakness, bloating, malaise, and a low-grade fever. The nurse suspects which condition? Pancreatitis Appendicitis Cholecystitis Diverticulitis

Diverticulitis Rationale: Although diverticula can occur at any point within the gastrointestinal tract, they are most common in the sigmoid colon; therefore, pain associated with diverticulitis occurs in the left lower quadrant. Pancreatitis is associated with acute epigastric or left upper quadrant pain. Appendicitis is associated with shifting of periumbilical pain to the lower right quadrant and localizing at McBurney's point. Cholecystitis is associated with right upper quadrant pain that may be referred to the right shoulder and scapula.

The nurse understands which anesthetic medication is commonly used for short procedures on pediatric clients? Fentanyl Morphine Meperidine Hydromorphone

Fentanyl Rationale: Fentanyl is recommended for short procedures on pediatric clients. For long procedures in which pain is anticipated even after the procedure, morphine should be administered. Meperidine and hydromorphone are used to achieve mild to moderate sedation in pediatric clients.

Which nursing concern is a priority when a 6-year-old child with sickle cell disease is admitted with a vasoocclusive crisis (pain episode)? Select all that apply. One, some, or all responses may be correct. Nutrition Hydration Pain management Prevention of infection Oxygen supplementation

Hydration Pain management Oxygen supplementation Rationale: The triad of treatment for a client experiencing a sickle cell crisis is hydration, pain management, and oxygenation. Hydration will provide more circulating volume for the sickle cells. Pain management is typically the primary reason this client presents for treatment; the pain becomes unbearable. Supplemental oxygen will provide more oxygen molecules to attach to the red cells, providing more oxygen to the tissue and joints. Other interventions such as nutrition and keeping the client safe from infection should be addressed but are not priorities.

Which route would a nurse expect to administer morphine sulfate prescribed for pain in a client admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior left arm? Orally Intravenously Subcutaneously Intramuscularly

Intravenously Rationale: The intravenous route is the preferred route for medication for a client with impaired peripheral circulation. Oral medications usually are not given to burn clients because of the frequent occurrence of paralytic ileus; oral analgesics take too long to provide immediate relief from pain. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered SQ.

Which pain relief medication would the nurse expect to find in the plan of care of a client with a myocardial infarction admitted to the cardiac intensive care unit? Morphine Diazepam Midazolam Oxycodone

Morphine Rationale: Morphine is the medication of choice for a myocardial infarction because it relieves pain quickly and reduces anxiety. It also decreases cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the severe pain associated with a myocardial infarction. Midazolam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the severe pain associated with a myocardial infarction. Oxycodone is an orally administered analgesic; an analgesic that is administered via the intravenous, not the oral, route provides more immediate pain relief.

Which group of clients who were in a bus accident and admitted to the emergency department with injuries is considered urgent according to the three-tier triage system? Sprains Simple fractures Severe abdominal pain Chest pain with diaphoresis

Severe abdominal pain Rationale: Severe abdominal pain is triaged under urgent type of tier level. It requires quick treatment but is not immediately life threatening. Sprains and simple fractures are triaged as nonurgent, which indicates the client could wait several hours if necessary without fear of the condition worsening. Chest pain with diaphoresis is triaged under emergent tier level because it is life threatening.

Which action would the nurse take before administering each dose in a client who takes oxycodone every 3 hours for pain after surgery? Select all that apply. One, some, or all responses may be correct. Count the client's respiratory rate. Examine the client for petechiae. Observe the client for movement disorders. Ask the client to rate the level of pain. Assess the client's level of consciousness.

Count the client's respiratory rate. Ask the client to rate the level of pain. Assess the client's level of consciousness. Rationale: Oxycodone is an opioid that depresses the central nervous system, resulting in depressed respirations and a decreased level of consciousness. The medication should be administered, delayed, or held, depending on the client's status. It is important to have the client rate the pain level as a basis for comparison when checking to see if the medication relieved the pain. Petechiae (or other signs of bleeding) and movement disorders are not associated with opioid use.

The nurse is planning the discharge of a 9-year-old child who has undergone tonsillectomy. In addition to the prescribed analgesic, which would the nurse recommend the parent use to ease their child's pain? Warm saline gargles Heating pad to the neck Light-colored ice pops Peppermint candy for sucking

Light-colored ice pops Rationale:Ice pops or ice chips provide a cool liquid that may be soothing to the oropharynx. Red, orange, or brown liquids are contraindicated because they mask bleeding. Gargling is contraindicated because it may traumatize the surgical site, resulting in bleeding; also, warm fluids promote capillary dilation, which may cause bleeding. A heating pad produces vasodilation, which may increase pain and promote bleeding. Hard candies can traumatize the surgical site and cause bleeding.

The nurse completes an admission assessment on a child with sickle cell anemia who is experiencing a painful vaso-occlusive crisis. Which nursing action would be a priority for the nurse to implement? Provide oxygen therapy Administer an analgesic Initiate a blood transfusion Monitor intravenous fluids

Administer an analgesic Rationale: The pain experienced by the vaso-occlusive crisis is caused by sickle-shaped red blood cells that block blood flow through tiny blood vessels to the chest, abdomen, joints, and bones. Pain management is priority. If the client has evidence of hypoxia, then oxygen should be administered. Although a blood transfusion may be needed to treat the anemia and intravenous fluids may be used to reduce the viscosity of the sickled blood, these interventions will not immediately relieve the pain.

The nurse is caring for a child with an exacerbation of leukemia. The nurse would plan to administer the prescribed analgesic for bone pain at which time? At scheduled intervals When the child asks for it When pain becomes severe Before the pain becomes severe

At scheduled intervals Rationale: For maximal benefit, the analgesic should be administered at scheduled intervals that are individualized for the child; routine administration manages the pain before it becomes too intense. The goal is to keep the child pain free; by the time the child asks for the analgesic, the pain has returned. It is insensitive to allow the child to be in pain; there should be no pain.

After an amputation of a limb, a client reports extreme discomfort in the area where the limb once was. Which goal would the nurse plan to focus interventions? Identifying actions to decrease pain in the lost limb Reversing feelings of hopelessness about the future Promoting mobility in the residual limb Facilitating the grieving process for the lost limb

Identifying actions to decrease pain in the lost limb Rationale: Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.

Which methods qualify as alternative therapies for pain? Select all that apply. One, some, or all responses may be correct. Prayer Hypnosis Medication Aromatherapy Guided imagery

Prayer Hypnosis Aromatherapy Guided imagery Rationale: Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

For which involuntary physiologic response would the nurse monitor development in a client experiencing pain? Crying Splinting Perspiring Grimincing

Perspiring Rationale: Perspiration is an involuntary physiologic response. It is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain. Crying is an emotional response that may or may not be related to pain. Splinting is a voluntary action that may limit tension on the abdomen, thus reducing pain. Grimacing is a result of contraction of the facial muscles; it may or may not be a response to pain.

Which nursing action is beneficial for the client who has pain due to muscle spasm? Providing heat compresses at the site Providing a massage to the affected area Encouraging the client to perform isometric exercises Encouraging the client to do active range-of-motion (ROM) exercises

Providing heat compresses at the site Rationale: The nurse provides thermotherapy (heat) to a client with muscle spasm. Heat compresses at the site of pain comfort the client by relaxing the muscle. A massage may stimulate muscle tissue contraction, which increases spasm and pain. The client with muscle spasm may not be able to perform isometric musclestrengthening exercises. The client may be encouraged to perform active range-ofmotion (ROM) exercises when the pain subsides.

Which response would the nurse give to a client newly diagnosed with multiple sclerosis who asks the nurse, "Will I experience pain?"? "Tell me about your fears regarding pain." "Analgesics will be prescribed to control the pain." "Pain is not a characteristic symptom of this condition." "Let's make a list of things to ask your primary health care provider."

"Pain is not a characteristic symptom of this condition." Rationale: The response "Pain is not a characteristic symptom of this condition" is a truthful answer that provides hope for the client. The response "Tell me about your fears regarding pain" avoids the client's question and can increase anxiety. Analgesics commonly are not prescribed unless pain results from some other condition. The response "Let's make a list of the things you need to ask your primary health care provider" avoids the client's question; the nurse should respond directly

When, during the first 24 hours postoperatively, will analgesics be administered to a client who undergoes an abdominal cholecystectomy for gangrene of the gallbladder? If repositioning is ineffective When the pain becomes severe In gradually increasing dosages As prescribed by the health care provider

As prescribed by the health care provider Rationale: Relief from pain helps the client cooperate with coughing, deep breathing, turning, and ambulating. These activities help prevent pneumonia, a frequent complication, because the proximity of the incision to the diaphragm limits lung expansion. Repositioning will not relieve pain associated with deep breathing and coughing, although it may relieve mild incisional pain. Analgesics should be given as prescribed to enable the client to successfully take part in postsurgical activity. Analgesics are less effective if given when pain has intensified; they should be given before pain is unbearable for best results. Pain is most intense during the first 24 hours, and analgesics should be administered as prescribed. Pain and analgesic dosages decrease gradually as the postoperative period progresses.

Which therapeutic outcome is expected after administering ibuprofen? Select all that apply. One, some, or all responses may be correct. Diuresis Pain relief Temperature reduction Bronchodilation Anticoagulation Reduced inflammation

Pain relief Temperature reduction Reduced inflammation Rationale: Prostaglandins accumulate at the site of an injury, causing pain; nonsteroidal antiinflammatory drugs (NSAIDs) like ibuprofen inhibit COX-1 and COX-2 (both are isoforms of the enzyme cyclooxygenase), which inhibit the production of prostaglandins, thereby contributing to analgesia. NSAIDs inhibit COX-2, which is associated with fever, thereby causing the temperature to decline. NSAIDs inhibition of COX-2 is associated with inflammation, thereby reducing inflammation. NSAIDs do not cause diuresis; reversible renal ischemia and renal insufficiency in clients with heart failure, cirrhosis, or hypovolemia can be potential adverse effects of NSAIDs. NSAIDs do not cause bronchodilation. Anticoagulation is an adverse effect, not a desired outcome; NSAIDs can impair platelet function by inhibiting thromboxane, an aggregating agent, resulting in bleeding.

An adolescent client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement? Turning on the television for diversion Placing the prescribed as-needed warm, wet compress on the elbow Calling the primary health care provider for another analgesic prescription Informing the client gently that they must wait until the pump reactivates to get more medication

Placing the prescribed as-needed warm, wet compress on the elbow Rationale: Vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump can be activated. Television may be an adequate distractor for mild pain, not moderate or severe pain. Nursing measures should be attempted first to relieve the pain before the primary health care provider is called. Telling the adolescent to wait provides no comfort.

Which client would be triaged under emergency severity index (ESI)-1 based on threat to life and stability of vital functions?

Rationale: Client B in cardiac arrest will have unstable vital functions of the ABCs (airwaybreathing-circulation) and a threat to life exists. The client should be triaged under the ESI-1 level and should be seen immediately by the primary health care provider. Client A with chest pain has threatened vital functions but is not unstable and should be seen within 1 hour. This type of client is categorized as ESI-2. Client C who has a simple laceration is categorized as ESI-4, which indicates that the vital functions are stable and the client has no immediate threat to life. Client D who has a hip fracture is triaged as ESI-3, which indicates that the vital function is stable and a threat to life is unlikely.

Which consideration is the nurse's concern when responding to the request of a hospice client who has severe pain and asks for another dose of oxycodone? Prevent addiction. Determine why the medication is needed. Provide alternative comfort measures. Reduce the client's pain.

Reduce the client's pain. Rationale: Hospice clients with severe pain need increasing levels of analgesics and should be maintained at a pain-free level, even if addiction occurs. Pain management, not the prevention of addiction, is the priority. The client has severe pain, and the priority is to relieve the pain. Comfort measures should augment, not be substitutes for, pharmacological interventions when clients are experiencing severe pain.

Which caring intervention helps provide comfort, dignity, respect, and peace to a client? Listening Spiritual caring Providing presence Relieving pain and suffering

Relieving pain and suffering Rationale: Relieving pain and suffering is not just about giving medications but includes providing comfort, dignity, respect, and peace to a client. Listening helps obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps convey closeness and a sense of caring.

At which time would the nurse plan to administer morphine 2 mg by mouth every 2 hours as needed to a client who has burns on 55% of the body surface and requires dressing changes? 15 minutes before the dressing change 60 minutes before the dressing change Along with a stool softener each time it is administered Only if the client rates pain between 8 and 10 on the pain scale

60 minutes before the dressing change Rationale: Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change. Although pain medications can cause constipation, the nurse would not administer a stool softener each time the morphine is administered. If the client is experiencing pain and rates it anywhere on the pain scale, the client can receive pain medication if it is within the time frame. It is important to premedicate a client before a painful procedure.

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? Ambulation Repositioning Purse-lipped breathing Deep breathing and coughing

Repositioning Rationale: Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain. Ambulation is not specifically used to decrease postoperative pain. Purselipped breathing is primarily used to improve ventilation. Deep breathing and coughing are used to clear the respiratory tract.

A child is administered fentanyl during outpatient surgery. The nurse understands which criteria must be met before the child can be discharged? Select all that apply. One, some, or all responses may be correct. The child is alert and active. The child's pain is at baseline levels. The child's body temperature is 102°F (38.9°C). The child's vital signs have remained stable. The child's oxygen saturation is 65% on room air.

The child is alert and active. The child's pain is at baseline levels. The child's vital signs have remained stable. Rationale: The child should be alert and oriented before being discharged. The child may be discharged if the pain has been reduced. The child's vital signs should be stable and consistent before the child is discharged. The child's body temperature should be below 101°F (38.3°C) before discharge. The child's oxygen saturation should be at least 95% on room air.

A client has been receiving oxycodone for moderate pain associated with multiple injuries sustained in a motor vehicle collision. Which assessment finding, in addition to the client's slurred speech, leads the nurse to suspect opioid intoxication? Mood lability Hypervigilance Constricted pupils Increased respirations

Constricted pupils Rationale: Pupil constriction is a physical sign of opioid intoxication or overdose. Opioids cause apathy or a depressed, sad mood (dysphoria); lability of mood is associated with the use of anabolic-androgenic steroids. Opioids cause drowsiness and psychomotor retardation; alertness is associated with the use of stimulants such as caffeine and amphetamines. Opioids depress the respiratory center of the brain, causing slow, shallow respirations; increases in temperature, pulse, respirations, and blood pressure are associated with cocaine use.

Which intervention would the nurse incorporate into the plan of care for the older adult experiencing chronic pain? Exercise Distraction Heat therapy Trigger point massage

Exercise Rationale: Exercise and client teaching are important nonpharmacological activities for older adults experiencing chronic pain. Exercise promotes movement of joints and muscle strength, and it can promote relaxation. Distraction may be valuable in clients with minor transient pain but is not used when the client is experiencing chronic pain. Heat therapy is not used for all types of chronic pain. Trigger point massage is not used for chronic pain

Which action is the nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. One, some, or all responses may be correct. Count the client's respirations. Document the intensity of the client's pain. Withhold the medication if the client reports pruritus. Verify the number of doses in the locked cabinet before administering the prescribed dose. Discard the medication in the client's toilet before leaving the room if the medication is refused.

Count the client's respirations. Document the intensity of the client's pain. Verify the number of doses in the locked cabinet before administering the prescribed dose. Rationale: Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect of opioids that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse would not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.

An adolescent client has orders for morphine sulfate for severe pain and acetaminophen-codeine compound for moderate pain after a spinal fusion. The pain assessment reveals the client is rigid and crying in pain. Which information would influence the nurse's choice of analgesic? One dose of morphine may be given, but the drug should be restricted thereafter because it is addictive. Adolescents tend to exaggerate their discomfort, particularly when they are immobilized by surgery or injury. Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic. The acetaminophen-codeine compound is preferred because morphine can cause respiratory depression or respiratory arrest.

Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic. Rationale: 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

Which conclusion would the nurse make regarding the client's response to pain medication when a client using a pain scale of 1 to 10 rates the pain as an 8 before receiving an analgesic and a 7 after being medicated? The client has a low pain tolerance. The medication is not adequately effective. The medication has sufficiently decreased the pain level. The client needs more education about the use of the pain scale.

The medication is not adequately effective. Rationale: The expected effect should be more than a 1-point decrease in the pain level. Whether a client has a low pain tolerance cannot be determined with the data available. The medication has not achieved an adequate response; pain generally is considered to be tolerable if it is 4 or below on a pain scale of 1 to 10. There is not sufficient data to determine whether the client needs more education about the use of the pain scale.

A client with a known history of opioid addiction has a surgical repair of multiple stab wounds to the abdomen. After surgery, the client's pain is not relieved by the prescribed morphine injections. Which phenomenon is the client experiencing when they fail to achieve pain relief? Tolerance Habituation Physical addiction Psychological dependence

Tolerance Rationale: Tolerance is a phenomenon that occurs in addicted individuals. It means that increasing amounts of the drug of addiction are required to satisfy need. The client should receive adequate analgesia after surgery. Drug habituation is a mild form of psychological dependence; the individual develops a habit of taking the substance. A physical addiction is related to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance for usual function. Psychological dependence is emotional reliance on the substance to maintain a sense of well-being.

Which information would the nurse include in the client's medication teaching on the administration of aspirin 650 mg every 6 hours as needed for arthritic pain? Select all that apply. One, some, or all responses may be correct. "Report persistent abdominal pain." "Do not chew enteric-coated tablets." "Take the aspirin with meals or a snack." "See a dentist if bleeding gums develop." "Switch to acetaminophen if tinnitus occurs."

"Report persistent abdominal pain." "Do not chew enteric-coated tablets." "Take the aspirin with meals or a snack." Rationale: Aspirin therapy may lead to gastrointestinal bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately. Entericcoated tablets must not be crushed or chewed. Aspirin is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner.

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F (38.3°C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, which clinical finding is a primary nursing concern for this client? Acute pain Inadequate nutrition Electrolyte imbalance Disturbed self-concept

Acute pain Rationale: Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation. Although clients with this medical diagnosis often are malnourished, addressing the client's pain takes priority. There are not enough data to determine electrolyte imbalance; additional data, such as for skin turgor, serum electrolytes, and intake and output, are needed to identify whether the client has a fluid and electrolyte imbalance. There are no data to support the presence of a disturbed self-concept.

Which order would the nurse identify as a priority nursing action after reviewing the prescriptions for the newly admitted emergency department client with urolithiasis? Strain the client's urine. Place the client in the high-Fowler position. Administer the prescribed morphine. Collect a urine specimen for culture and sensitivity

Administer the prescribed morphine. Rationale: Pain relief is the priority. Client's report that ureteral colic is excruciatingly painful. Once pain is under control and the client is comfortable, the nurse may implement the other medical and nursing interventions. Although straining all urine is required, pain relief is the priority. Once the client receives the medication for pain control, the nurse will be able to strain the set-aside urine specimen. The highFowler position is not necessary. The client can be assisted to assume a position of comfort. The emergency department will have sent the urine to the laboratory for a culture and sensitivity.

Which action would the nurse take first for a postsurgical client who is still intubated but becoming restless, with an increased pulse rate and blood pressure, when it has been 4 hours since the last dose of pain medication? Notify the provider. Perform a full physical assessment. Administer the prescribed pain medication. Play soft, relaxing music to help calm the client.

Administer the prescribed pain medication. Rationale: Because the client is intubated, the nurse cannot fully assess for pain, but the person is displaying signs of it. The nurse would administer the prescribed pain medication, especially if it has been several hours since the last dose. There is no need to notify the provider or perform a full physical assessment. Playing soft, relaxing music, although it can help relieve pain, is not the best action for a postsurgical client because it is not sufficient to manage pain.

Which recommendation would the nurse give to the client with trigeminal neuralgia? Drink iced liquids. Avoid oral hygiene. Apply warm compresses. Chew on the unaffected side

Chew on the unaffected side Rationale: The client may avoid stimulating the involved trigeminal nerve and thus prevent pain by chewing on the unaffected side. Food and fluids that are too hot or too cold can precipitate pain. Although oral hygiene may initiate pain, it cannot be avoided. It can be modified to include rinsing the mouth or using a soft swab instead of a toothbrush. Warm compresses may precipitate pain.

Which benefit would be provided by administering patient-controlled analgesia (PCA) to a client after surgery? Select all that apply. One, some, or all responses may be correct. Client is able to self-administer pain-relieving medications as necessary Amount of medication received is determined entirely by the client Decreases client dependency Relieves the nurse of monitoring the client Increases client sense of autonomy

Client is able to self-administer pain-relieving medications as necessary. Decreases client dependency Increases client sense of autonomy Rationale: The purpose of patient-controlled analgesia is to give the client the ability to selfadminister pain-relieving medications as necessary; usually smaller amounts of analgesics are used with self-administration. The amount and dosage of the medication are programmed to prevent accidents or abuse. Medication levels are kept in a maintenance range, and pain relief is achieved without extreme fluctuations. The client isn't dependent on the nurse availability to administer medication. This increases the client's sense of autonomy. The nurse is not absolved of responsibility when PCA is used; monitoring the client for effectiveness, refilling the apparatus with the prescribed narcotic, and charting the amount administered and the client's response are required.

Which action would the nurse take while giving an injection to a preschooler? Ask the parent to restrain the child. Distract the child with conversation. Avoid awakening the child if asleep. Avoid using lidocaine ointment over the injection site.

Distract the child with conversation. Rationale: Distracting the preschooler with conversation, bubbles, or a toy reduces the child's pain perception. The nurse should not ask the parent to restrain the child because this may cause the child to develop a negative association with health care and interventions. Before giving an injection, the nurse should awaken the child. The nurse may apply lidocaine ointment over the injection site to reduce pain perception.

After obtaining vital sign data of blood pressure 90/60 mm Hg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which priority action would the nurse take? Give naloxone intravenously per protocol. Assess the client's pain level on a 10-point scale. Document the vital signs in the client record. Notify the hospital rapid respo

Give naloxone intravenously per protocol. Rationale: A respiratory rate of 10 breaths/minute is abnormal and indicates oversedation with hydromorphone, which should be treated immediately with naloxone administration. Pain level would be assessed, but it is not as high a priority as reversing the opiate-induced respiratory depression. Documentation of findings also needs to be done, but this can be done after naloxone administration. The rapid response team may also be activated, but the nurse would not wait for the rapid response team to give the naloxone

A client with a history of osteoporosis and vertebral compression has been coming to the clinic more frequently for prescription refills of hydrocodone/acetaminophen. Which inference will the nurse make? The half-life of the medication has decreased. An idiosyncratic reaction has occurred. Higher doses are needed to achieve pain relief. An emotional dependence on the medication has developed.

Higher doses are needed to achieve pain relief. Rationale: As the body adapts to the medication (tolerance), an increased dose is needed to produce the desired effect. The half-life of a medication does not change and is related to the time required for it to be absorbed, distributed, metabolized, and excreted from the body. Idiosyncratic reactions are unpredictable; these sporadic reactions are unrelated to dosage. The data are insufficient for the nurse to conclude that emotional or physiological dependence has developed.

An adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. Which are the primary purposes of administering pain medication via the intravenous route, rather than the intramuscular route? Select all that apply. One, some, or all responses may be correct. Adolescents are afraid of injections. It decreases the risk of tissue irritation. Severe pain is reduced more effectively. Impaired peripheral circulation is bypassed. It provides for more prolonged relief of pain.

It decreases the risk of tissue irritation. Severe pain is reduced more effectively. Impaired peripheral circulation is bypassed. Rationale: Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury. The medication begins to work in minutes; doses can be controlled. Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue. Stating that adolescents are afraid of injections is a generalization that is not necessarily true. The duration of effectiveness of an analgesic is based on its therapeutic level in the body, regardless of what route is used.

Which assessment finding of a client with chronic pain who has been prescribed opioid treatment indicates the need for a priority nursing intervention? Select all that apply. One, some, or all responses may be correct. Level 3 sedation Nausea and vomiting Respiratory rate of 8 breaths per minute Pruritus Constipation

Respiratory rate of 8 breaths per minute and Level 3 sedation Rationale: Chronic use of opioids for pain may lead to constipation, nausea, vomiting, sedation, and respiratory distress. The client with a level 3 of sedation has frequent drowsiness, arousals, and episodes of sleep during conversation and needs immediate intervention. A respiratory rate of 8 breaths per minute leads to respiratory distress, which must be supported by adequate oxygenation. Pruritus can be resolved slowly because it is less life-threatening. Constipation can be relieved by providing the client with a stimulant laxative and a stool softener. Nausea and vomiting may be resolved by providing antiemetics to the client.

Which response by the nurse asked "How will they 'knock me out' for this colonoscopy?" describes the route of administration for conscious sedation? "The medicine will be injected into your spine." "You will receive the anesthesia through a face mask." "You will receive medication through an intravenous (IV) catheter." "We will give you an oral medication about 1 hour before the procedure.

"You will receive medication through an intravenous (IV) catheter." Rationale: Conscious sedation is administered by direct IV injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without the loss of defensive reflexes. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) space; it works by binding to nerve roots as they enter and exit the spinal cord. Epidural blocks are not used for moderate sedation. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. The oral route of medication administration is commonly used for pediatric clients, not adults.

Twenty-four hours after receiving spinal anesthesia during childbirth, a client tells the nurse she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply. One, some, or all responses may be correct. 'My ears are ringing.' 'It gets better when I lie down.' 'Bright lights really bother my eyes.' 'It gets better as soon as I walk a while.' 'My head hurts more when I'm sitting watching television.' 'My head hurts more when I'm lying on my side breast-feeding.'

'My ears are ringing.' 'It gets better when I lie down.' 'Bright lights really bother my eyes.' 'My head hurts more when I'm sitting watching television.' Rationale: A headache resulting from spinal anesthesia usually occurs 24 to 72 hours after administration. Central nervous system irritation can cause auditory problems such as tinnitus. Postural changes cause the diminished volume of cerebrospinal fluid to exert traction on pain-sensitive central nervous system structures. The client is most comfortable when lying flat. Central nervous system irritation can cause visual problems such as photophobia and blurred vision. This type of headache will worsen when the client is ambulatory or assumes an upright position.

Which pain description would the nurse expect a client to report when describing pain associated with a suspected duodenal peptic ulcer? An ache radiating to McBurney point An intermittent, colicky right-flank pain A gnawing sensation in the epigastric area

A gnawing sensation in the epigastric area Rationale: Peptic ulcer pain is usually described as a gnawing sensation and is often caused by Helicobacter pylori and nonsteroidal anti-inflammatory drugs (NSAIDS). An ache radiating to the left side is not specific to duodenal ulcers. An intermittent, colicky flank pain may indicate renal colic. A generalized abdominal pain intensified by moving is not specific to duodenal ulcers.

Which intervention is useful in promoting comfort for the client experiencing a headache? Massage Heat therapy Cold therapy Relaxation strategies

Cold therapy Rationale: Cold therapy is believed to be more effective than heat for a variety of painful conditions such as headaches. Massage can be useful for acute or chronic pain but is not specifically used to treat headaches. Heat therapy can be used for superficial or deep tissue pain, but not for the treatment of headaches. Relaxation techniques are used to enhance the effectiveness of other pain relief measures.

Which situation would the nurse address first according to Maslow's hierarchy? Has history of being injured from sudden falls Complains of sleeplessness due to pain postsurgery Reports that they feel lonely and socially isolated Conveys to the nurse that they want to become the manager of the company

Complains of sleeplessness due to pain postsurgery Rationale: According to Maslowu2019s hierarchy of needs, the nurse would address the physiological needs of the client first. In the given scenarios, the nurse would ideally attend to the client who complains of sleeplessness due to pain postsurgery on a priority basis. Then, the nurse would attend to the client who has a history of getting injured from sudden falls as it comes under safety and security needs. After this, the nurse would attend to the client who complains that feels lonely and socially isolated as this falls under self-esteem needs. When a client conveys to the nurse that they want to become the manager of the company, the nurse understands this to be a self-actualization need. This is the highest-level need and would be addressed last.

Which action would the nurse take when caring for a client using a patient-controlled analgesia pump who identifies attempts to selfadminister the analgesic 10 times because the client is still experiencing pain? Monitor the client's pain level for another hour. Determine the integrity of the intravenous delivery system. Reprogram the pump to deliver a bolus dose every 8 minutes. Arrange for the client to be evaluated by the health care provider.

Determine the integrity of the intravenous delivery system. Rationale: Initially, the integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider's prescription. The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised, the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.

Which factors would the nurse consider when administering opioids to a child with severe pain? Select all that apply. One, some, or all responses may be correct. Diet modification Dosing calculations Body mass index Appropriate dosage form Presence of other symptoms

Dosing calculations Appropriate dosage form Presence of other symptoms Rationale: While administering opioids in children, the dose must be calculated and doublechecked to avoid errors because excessive doses may be fatal in children. Proper dosage forms such as oral, subcutaneous, and rectal administration of drugs should be chosen according to the client's condition. Opioids may cause side effects such as hallucinations and dizziness; therefore the child should be monitored for signs and symptoms indicating side effects. Diet modification and information on body mass index of the client is not required for the administration of opioids.

Based on the information in this chart, which adolescent may require a modified treatment plan?

Dysmenorrhea causes a release of prostaglandin F2-alpha. Acetaminophen does not have antiprostaglandin properties and may not help relieve pain associated with dysmenorrhea. Ibuprofen may be a preferred alternative treatment. Chaste tree fruit is an herbal supplement used to treat menorrhea. Endometriosis can be treated with oral contraceptives. Ibuprofen can be used to treat breast pain.

The nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun to care for the client. Which is the best nursing intervention in preparing for the client's discharge? Contact the client's health care provider to ask to substitute a liquid form of medications for the pill form. Teach the client and family members to crush the pills and administer them with applesauce. Contact the client's health care provider to discuss use of transdermal medications for pain control. Teach the client and family members about addiction that may occur as a result of regular opioid use.

Contact the client's health care provider to discuss use of transdermal medications for pain control. Rationale: The client will be discharged home with hospice, and there is no chance that dysphagia will be relieved by surgery or will improve by other measures. Considering that the client is approaching death and the client's condition is deteriorating, the transdermal route of administration of the pain medications is less invasive and provides comfort. The liquid form of pain medication or crushing the pills and administering them with applesauce is not possible because the client has dysphagia. The client is approaching the end of life and requires comfort measures; therefore, opioid addiction is not a nursing concern for the dying client.

A child is experiencing pain after abdominal surgery and is given an opioid analgesic. Which statement is correct regarding children in pain and their response to opioid analgesics when they are prescribed? Addiction to opioids is more of a risk for children than adults. Analgesics are not needed as frequently because pain is not as strongly felt by children as it is by adults. Even though children do not like taking medicines, analgesics will make them more comfortable. Children do not need analgesics because they are easily distracted and will quickly return to play or sleep.

Even though children do not like taking medicines, analgesics will make them more comfortable. Rationale: Children are as much in need of analgesics for relief of pain as adults are. It is an unsound belief that children are more prone to opioid addiction than adults are. It is a myth that children do not feel pain as strongly as adults; it is difficult for children to communicate pain. Playing or trying to sleep may be the child's way of coping with pain; however, the fact that the child engages in these behaviors is not a reason to withhold an analgesic.

A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take? Instruct the client to splint the wound with a pillow when coughing. Place the client in the supine position and inspect the site of the incision. Assess the intensity of the pain and administer the prescribed analgesic. Notify the health care provider immediately and then check for wound dehiscence.

Instruct the client to splint the wound with a pillow when coughing. Rationale: Supporting the wound with a pillow when coughing relieves some of the pain because it provides support to the incised chest wall. Pain at the incision site when coughing and deep breathing is expected; it does not indicate a need to place the client in the supine position and to inspect the wound site. Analgesics will not relieve the discomfort associated with coughing unless stress placed on the incision by coughing is relieved. Pain at the incision site just when coughing and deep breathing is expected; it does not indicate a need to call the health care provider and then check for wound dehiscence.

Which action would be taken by a nurse when caring for a client prescribed transdermal fentanyl 25 mcg/h every 72 hours during the first 24 hours after starting the fentanyl? Titrate the dose until pain is tolerable. Manage pain with an analgesic by a different route. Assess the client for anticholinergic side effects. Instruct the client to take the medication with food.

Manage pain with an analgesic by a different route. Rationale: It takes 24 hours to reach the peak effect of transdermal fentanyl. An alternate-route pain medication may be necessary to support client comfort until the fentanyl reaches its peak effect. The nurse needs to administer the dose of transdermal fentanyl exactly as prescribed by the health care provider. Anticholinergic side effects are associated with tricyclic antidepressants, not transdermal fentanyl. A transdermal medication is administered through the skin via a patch applied to the skin, not via the gastrointestinal tract.

Six hours after major abdominal surgery, a client reports severe abdominal pain and faintness. The nurse identifies a thready, rapid pulse. The nurse checks the medication administration record (MAR) and determines that the client can receive another injection of pain medication in an hour. Which action would the nurse take? Notify the health care provider about the client's symptoms. Explain to the client that it is too early to have an injection for pain. Reposition the client for greater comfort and turn on the television as a distraction. Prepare the injection to administer it to the client early because of the severe pain.

Notify the health care provider about the client's symptoms. Rationale:The client's signs and symptoms suggest the possibility of shock; the primary health care provider must be alerted to this possibly life-threatening condition. Explaining to the client that it is too early is missing the big picture; the client may be hemorrhaging. The client has unmet needs that must be addressed first. Distraction is effective with mild, not severe, pain. Preparing and administering the pain medication early are outside the scope of nursing practice. Health care provider prescriptions must be followed as prescribed, or the health care provider should be notified.

When providing comfort to a client during the last hours of life, which would be the nurse's primary concern? Select all that apply. One, some, or all responses may be correct. Pain Nutrition Elimination Respiratory status Cardiovascular status

Pain and respiratory status Rationale: In the last hours of a client's life, assessments are limited to only those that are needed to determine comfort. Assessment of pain and the respiratory status will be the most important at this time. The nurse can administer pain prescriptions to relieve discomfort and oxygen to help the client breathe easier. Nutrition, elimination, and cardiovascular status are not the primary focus in the last hours of life, because the death is imminent.

Which client would need a correction in the nursing intervention?

Rationale: When a child has acute pain, oral dosage forms of analgesics should be given. These medications must be given before the pain intensifies, so the nursing intervention for client 2 needs correction. In pediatrics, distraction and creative imagery during the medication administration can help distract the child from any pain or fear, so the nursing intervention for client 1 is appropriate. In pediatrics, opioids can cause certain changes such as nausea and vomiting. Administering the medications with meals can help reduce the gastrointestinal (GI) upset, so the nursing intervention for client 3 is appropriate. While administering suppositories to pediatric clients, care should be taken that an adult dose is halved, split, or divided to reduce the risk of overdose, so the nursing intervention for client 4 is appropriate.

Which intervention is the priority nursing care for a client in the coronary care unit who develops "viselike " chest pain radiating to the neck with a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis who is prescribed morphine sulfate 4 mg intravenous (IV) push stat and cardiac monitoring? Relief of pain Client teaching Cardiac monitoring Maintenance of bed rest

Relief of pain Rationale: Unrelieved chest pain increases anxiety, fatigue, and myocardial oxygen consumption, with the possibility of extending the infarction. The client will not be ready for teaching until the chest pain is relieved. The morphine will decrease cardiac workload and, thereby, decrease oxygen demand. Cardiac monitoring is important, but it does not take priority over relieving the chest pain. Bed rest is necessary to decrease the workload of the heart but decreasing the cardiac workload will be difficult to achieve unless the chest pain is relieved

Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? Remove the IV catheter and restart the saline lock in another site. Document the findings per protocol and reassess the site in 8 hours. Flush the IV catheter and saline lock again vigorously with normal saline. Change the dressing and apply a new clean dressing per IV care protocol.

Remove the IV catheter and restart the saline lock in another site. Rationale: The client's report of pain and burning at the site indicates that the tip of the catheter is no longer in the vein and the client needs removal of the current catheter and a new IV access site. Documenting the findings and then reassessing the site in 8 hours would leave the client with no IV access. Flushing vigorously will lead to more pain as more saline is pushed into the infiltrated site. Changing the dressing would leave the client without a patent IV access.

After orthopedic surgery, an adolescent reports pain and rates it a 5 on a scale of 0 to 10. The nurse administers the prescribed 5 mg of oxycodone every 3 hours as needed. Two hours after having been given this medication, the adolescent reports pain and rates it a 10 of 10. Which action would the nurse take? Administer another dose of oxycodone within 30 minutes. Report the adolescent's apparent idiosyncratic reaction to oxycodone. Tell the adolescent that additional medication cannot be given for 1 more hour. Request that the primary health care provider evaluate the need for additional medication.

Request that the primary health care provider evaluate the need for additional medication. Rationale: The nurse has made the assessment that the medication has been ineffective in relieving the adolescent's pain for the duration that it was prescribed to cover. This information should be communicated to the primary health care provider for evaluation. The prescription is for administration every 3 hours; legally the medication may be given only within these guidelines. There are no data to support an idiosyncratic reaction to the oxycodone; the amount of medication was probably inadequate for the adolescent's pain tolerance level. The nurse would not ignore the adolescent's need for pain relief.

The primary nurse, leaving the unit for lunch, provides a verbal report for the covering nurse. The report included one client's prescription for morphine: 2 mg intravenously (IV) every 3 hours for abdominal pain secondary to major abdominal surgery that morning. During the primary nurse's lunch, the client complains of pain at a level 8 out of 10 on the pain scale. Which action would the covering nurse perform first? Determine the documented time of the last administration of pain medication. Verify that the written prescription matches the administration record. Encourage nonpharmacological measures initially to relieve the pain. Explain that the primary nurse will be back from lunch in a few minutes.

Verify that the written prescription matches the administration record. Rationale: 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 written by the health care provider 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 at a level 8 on a 0 to 10 scale that is associated with recent major abdominal surgery. The client's pain must be addressed immediately. The covering nurse should verify and give the pain medication as prescribed.