Module 8 Flashcards
The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.
Delegate pain assessment to the UAP.
Assess for pain control 30 minutes after administering an analgesic.
Consider cultural implications of the perception of pain. Infer that the client who does not complain has no pain.
Provide pain medication before activity that may increase pain.
Provide pain medication before activity that may increase pain.
Assess for pain control 30 minutes after administering an analgesic.
Consider cultural implications of the perception of pain.
The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment?
Respiratory status, oxygen saturation, pain, and sedation level
Explanation:
Respiratory status, oxygen saturation, pain, and sedation level are the best description of the priority of the hourly assessments for this client. The priority concern for this client is the risk of respiratory depression because of the use of analgesia; therefore, the priority assessments during the first 12 hours of epidural therapy include assessing the client’s vital signs, respiratory status, pain status, sedation level, oxygen saturation at least once per hour during the first 12 hours of therapy. If there are no complications after 12 hours, the assessments should continue every 2 hours and then decrease per facility policy. Airway, breathing, and circulation are the top priorities in the care of any client, and in this client, breathing is a concern because of the risk of respiratory depression from the epidural analgesia
The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?
“This will allow me to control my own pain medication.”
“I should only take medication when my pain is intense.”
“I give myself the pain medication by pushing the button.”
“The pump is programmed to limit the chance of overmedicating.”
“I should only take medication when my pain is intense.”
A client with recurrent episodes of migraine headaches tells the nurse, “I am not comfortable taking medication for my pain.” Which pain relief technique(s) can the nurse teach the client to implement at home?
relaxation
massage
meditation
biofeedback
A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?
The dose that is delivered when the client activates the machine is preset.
A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse?
Administer the medication if respiratory rate is > 9.
A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?
Opioid analgesics
The nurse manager hears a nurse and a nurse aide talking about a female client who reports pain of 8 out of 10 on a 1-10 scale after a Caesarean birth to deliver twins. The nurse states, “I don’t believe this client has any pain at all. I’m sure she is just drug seeking.” What is the appropriate nurse manager action?
Ask the nurse to speak privately for a moment, and educate about bias in pain treatment.
When asking an older adult client about abdominal pain, the client reports, “I don’t want to be a bother because nothing hurts too much.” The nurse notes that the client grimaces and splints the abdomen when moving. What is the appropriate nursing action?
Gently mention that the client appears to be experiencing pain that can be treated
A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client’s room to administer the medication, the client is laughing with visitors. The client’s pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?
Administer the pain medication.
The nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision?
verbal report
The nurse recognizes which statement is true of chronic pain?
It may cause depression in clients
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?
“Can you describe the type of pain you are having?”
The wife of a client with cancer is concerned that her husband’s breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of:
tolerance.
A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?
visceral pain
Explanation:
Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client’s pain is sensed near the location of his appendix.
A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?
neuropathic pain
Explanation:
The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. In cutaneous pain, the discomfort originates at the skin level. In visceral pain, the discomfort arises from internal organs caused from a disease or injury. In chronic pain, the discomfort lasts longer than 6 months.
A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?
“The pump is programmed with safeguards to limit the possibility overmedication.”
A client in pain believes that the pain is a punishment from God, and feels angry and resentful. Which is the most appropriate action by the nurse?
Encourage client to confer with a spiritual advisor.
A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?
The client is actively involved in pain management.
After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?
3
Explanation:
The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows:
1 = awake and alert; no action necessary
2 = occasionally drowsy but easy to arouse; requires no action
3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose
4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.
You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?
When obtaining patient vital signs
A client who is living with chronic pain has received a health care provider’s order for TENS. When applying the device to the client’s skin, the nurse should do what action?
Start with the lowest intensity and gradually increase it to the appropriate level.
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client’s respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?
Administration of 0.4 mg of naloxone
Explanation:
The client is experiencing impending respiratory arrest due to the effect of the medication and this should be reversed immediately prior to arrest. This is the priority action and will correct the respiratory depression immediately. CPR is not indicated at this time, because the client is not in full arrest. Placing the client in the supine position may decrease respirations further.
While caring for a client with chronic pain, the nurse talks with a family member. Which family member statement does the nurse identify as consistent with caregiver role strain?
“Sometimes it seems like I can never get a moment to myself.”
Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?
Pain assessment may require multiple methods in order to ensure accurate pain data.
A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first?
Stop the PCA pump.
Explanation:
A side effect of morphine is respiratory depression. In this situation, the nurse should first stop the PCA pump and then notify the physician. Naloxone is used to reverse the sedative effects of opioids, but this is not the first step.
