NCLEX - W13 - Pain

Question 1

A patient reports pain rated as 7 out of 10. What type of pain relief intervention would be most appropriate for the nurse to implement first?
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A. Administer a nonopioid analgesic, such as ibuprofen.
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B. Administer an opioid analgesic, such as morphine.
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C. Use distraction techniques, such as conversation or music.
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D. Provide cutaneous stimulation, such as a back rub.

Answer 1

Answer: A.

Rationale: Nonopioid analgesics, like ibuprofen, are appropriate first-line treatments for mild to moderate pain. Opioid analgesics are reserved for moderate to severe pain. Distraction and cutaneous stimulation can be helpful adjuncts but are not typically sufficient for pain rated as 7 out of 10.

Question 2

Which statement by a patient indicates a need for further teaching about patient-controlled analgesia (PCA)?
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A. “I can push the button whenever I feel pain.”
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B. “My family can push the button for me when I’m asleep.”
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C. “I should tell the nurse if the medication isn’t controlling my pain.”
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D. “I might feel sleepy after taking the medication.”

Answer 2

Answer: B.

Rationale: Only the patient should push the PCA button to ensure they receive the appropriate dose based on their pain level. Family members should not administer medication via PCA. The other statements indicate understanding of PCA use.

Question 3

An older adult patient reports experiencing chronic pain. Which factor is most important for the nurse to consider when assessing this patient’s pain?
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A. Older adults are more sensitive to pain and require lower doses of analgesics.
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B. Pain is a normal part of aging and does not require aggressive treatment.
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C. Older adults may have difficulty communicating their pain or may underreport it.
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D. Older adults metabolize medications faster and may require more frequent dosing.

Answer 3

Answer: C.

Rationale: Older adults may be reluctant to report pain or may have cognitive impairments that affect their ability to communicate their pain effectively. It is crucial for nurses to carefully assess pain in older adults and recognize that pain is not a normal part of aging

Question 4

The nurse is caring for a patient with a history of opioid addiction who is hospitalized for acute pain management. What is the most important principle for the nurse to apply when managing this patient’s pain?
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A. Avoid administering opioids to prevent the risk of relapse.
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B. Use nonpharmacological interventions exclusively to manage pain.
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C. Administer the lowest effective opioid dose and monitor for signs of abuse.
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D. Treat the patient’s addiction before addressing their acute pain.

Answer 4

Answer: C.

Rationale: Patients with a history of opioid addiction still require adequate pain relief. The nurse should carefully administer the lowest effective opioid dose, monitor for signs of abuse, and consider a multidisciplinary approach involving pain specialists and addiction counselors

Question 5

A patient is receiving morphine sulfate via PCA for postoperative pain. What is the most important nursing action to prevent respiratory depression in this patient?
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A. Monitor the patient’s sedation level and respiratory rate frequently.
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B. Teach the patient to use the PCA button only when pain is severe.
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C. Administer a stool softener to prevent opioid-induced constipation.
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D. Encourage the patient to ambulate frequently to promote lung expansion.

Answer 5

Answer: A.

Rationale: Respiratory depression is a serious side effect of opioid medications. Monitoring the patient’s sedation level and respiratory rate is crucial to identify early signs of respiratory depression.

Question 6

A patient with chronic back pain is prescribed a TENS unit for pain management. What teaching point is most important for the nurse to include when educating the patient about TENS?
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A. The electrodes should be placed directly over the area of pain.
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B. TENS is a cure for chronic pain and can eliminate the need for medication.
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C. TENS works by stimulating large nerve fibers to block pain signals.
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D. TENS is a form of heat therapy and should not be used with other heating pads.

Answer 6

Answer: C.

Rationale: TENS units work based on the gate-control theory of pain, stimulating large nerve fibers to block pain signals. It is not a cure for chronic pain, and electrodes should not be placed directly over the area of pain. TENS does not use heat.

Question 7

Which nonpharmacological intervention would be most appropriate for a patient experiencing pain related to labor contractions?
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A. Massage and effleurage
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B. Application of a cold compress
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C. Distraction with television
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D. Immobilization of the affected area

Answer 7

Answer: A.

Rationale: Massage and effleurage can provide comfort and pain relief during labor by promoting relaxation and stimulating the release of endorphins.

Question 8

What is the priority nursing action when caring for a patient experiencing acute pain?
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A. Administer a placebo to determine if the pain is real.
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B. Delay pain management interventions until the pain is severe.
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C. Assess the patient’s pain level and administer analgesics as ordered.
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D. Encourage the patient to endure the pain to avoid medication dependence.

Answer 8

Answer: C.

Rationale: Nurses are ethically obligated to assess and manage pain. Administering analgesics as ordered and promptly addressing pain are essential nursing actions.

Question 9

What type of pain is most likely to respond well to opioid analgesics?
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A. Neuropathic pain
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B. Visceral pain
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C. Somatic pain
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D. Psychogenic pain

Answer 9

Answer: B.

Rationale: Visceral pain, originating from internal organs, is generally more responsive to opioid analgesics.

Question 10

A patient with a history of chronic pain is being discharged from the hospital. What is the most important information for the nurse to include in the discharge teaching plan?
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A. The importance of accepting pain as a part of life
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B. Techniques for concealing pain from family and friends
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C. Strategies for managing pain and preventing exacerbations
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D. The risks associated with long-term use of nonopioid analgesics

Answer 10

Answer: C.

Rationale: Empowering patients with strategies for managing their pain and preventing exacerbations is essential for promoting self-care and improving quality of life

Question 11

Which statement best describes the concept of pain tolerance?
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A. The point at which a person first feels pain
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B. The amount of pain a person can endure before seeking relief
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C. The physiological process of pain transmission in the body
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D. The emotional response to a painful stimulus

Answer 11

Answer: B.

Rationale: Pain tolerance refers to the duration or intensity of pain an individual can withstand before seeking relief. It varies greatly among individuals and can be influenced by factors such as age, culture, and previous pain experiences.

Question 12

A nurse is caring for a patient receiving epidural analgesia. Which assessment finding requires immediate nursing intervention?
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A. Respiratory rate of 10 breaths per minute
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B. Blood pressure of 110/70 mmHg
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C. Pain level of 3 out of 10
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D. Temperature of 99.2°F (37.3°C)

Answer 12

Answer: A.

Rationale: A respiratory rate of 10 breaths per minute is below the normal range and suggests possible respiratory depression, a serious side effect of epidural analgesia.

Question 13

Which side effect is commonly associated with the administration of opioid analgesics?
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A. Diarrhea
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B. Urinary frequency
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C. Constipation
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D. Hypertension

Answer 13

Answer: C.

Rationale: Constipation is a frequent side effect of opioids, resulting from decreased bowel motility.

Question 14

Which nonpharmacological pain relief measure is based on the gate-control theory of pain?
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A. Acupuncture
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B. Meditation
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C. Guided imagery
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D. Massage

Answer 14

Answer: D.

Rationale: Massage, like TENS, stimulates large nerve fibers, closing the gate to pain signals in the spinal cord.

Question 15

What is the primary role of adjuvant analgesics in pain management?
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A. To replace opioid analgesics in treating severe pain
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B. To enhance the effects of opioids or address specific types of pain
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C. To provide sedation and reduce anxiety related to pain
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D. To prevent the development of tolerance to opioid medications.

Answer 15

Answer: B.

Rationale: Adjuvant analgesics, such as antidepressants and anticonvulsants, are used alongside opioids to increase pain relief or address neuropathic pain

Question 16

A patient with cancer pain is prescribed a fentanyl transdermal patch. What instruction is crucial for the nurse to provide to the patient and family regarding patch disposal?
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A. Flush the used patch down the toilet.
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B. Cut the used patch into small pieces before discarding.
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C. Fold the used patch in half and secure it with tape before disposal.
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D. Place the used patch in a sharps container for safe disposal.

Answer 16

Answer: C.

Rationale: Proper disposal of fentanyl patches is essential to prevent accidental exposure and overdose. Folding the patch in half and securing it with tape minimizes the risk of medication leakage.

Question 17

What is the rationale for using a multimodal approach to pain management?
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A. To eliminate the need for opioid analgesics
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B. To target multiple pain pathways and reduce side effects
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C. To simplify medication regimens and improve patient adherence
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D. To reduce the cost of pain management interventions

Answer 17

Answer: B.

Rationale: Multimodal pain management aims to address pain through various mechanisms, using different types of medications and therapies to maximize pain relief while minimizing the side effects of individual treatments.

Question 18

A patient with severe burns is receiving intravenous morphine sulfate for pain management. The nurse observes that the patient is lethargic and difficult to arouse. What is the priority nursing action?
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A. Stop the morphine infusion and administer naloxone.
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B. Reduce the morphine infusion rate and notify the provider.
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C. Administer a stimulant medication to counteract the sedation.
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D. Continue to monitor the patient’s sedation level and vital signs closely.

Answer 18

Answer: B.

Rationale: Lethargy and difficulty arousing suggest excessive sedation, a precursor to respiratory depression. Reducing the morphine infusion rate and notifying the provider are essential steps to prevent further respiratory compromise.

Question 19

Which pain scale would be most appropriate for assessing a 4-year-old child’s pain level?
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A. Numeric Rating Scale (NRS)
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B. Visual Analog Scale (VAS)
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C. FACES Pain Scale
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D. Wong-Baker FACES Pain Rating Scale

Answer 19

Answer: D.

Rationale: The Wong-Baker FACES Pain Rating Scale, with its simple illustrations of faces representing different pain levels, is suitable for young children who may have difficulty understanding numerical scales or verbal descriptions of pain.

Question 20

A patient reports experiencing breakthrough pain despite receiving regular doses of opioid medication. What is the most likely explanation for this type of pain?
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A. The patient has developed tolerance to the opioid medication.
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B. The patient is exaggerating their pain level to obtain more medication.
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C. The patient is experiencing a new source of pain unrelated to their initial condition.
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D. The patient’s pain medication is not being administered correctly.

Answer 20

Answer: C.

Rationale: Breakthrough pain is a transient exacerbation of pain that occurs in patients already receiving analgesics for persistent pain. It is often caused by a new or worsening pain source.

Question 21

Which physiological response is associated with the activation of the sympathetic nervous system in response to acute pain?
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A. Decreased heart rate
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B. Increased blood pressure
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C. Constricted pupils
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D. Decreased respiratory rate

Answer 21

Answer: B.

Rationale: The sympathetic nervous system triggers a “fight-or-flight” response to acute pain, leading to physiological changes, including increased heart rate, blood pressure, and respiratory rate

Question 22

A patient with dementia is exhibiting signs of pain, including grimacing and agitation. What is the most reliable method for the nurse to assess pain in this patient?
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A. Ask the patient to rate their pain level using a numerical scale.
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B. Observe the patient’s behavior and nonverbal cues for pain indicators.
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C. Rely on the patient’s family to report the patient’s pain level.
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D. Use physiological measures, such as vital signs, as the primary indicator of pain.

Answer 22

Answer: B.

Rationale: Patients with dementia may be unable to communicate their pain verbally. Observing behavioral cues, such as facial expressions, vocalizations, and changes in physical activity, is essential for pain assessment in this population

Question 23

Which type of pain is characterized as being chronic and resistant to relief?
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A. Acute pain
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B. Breakthrough pain
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C. Intractable pain
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D. Neuropathic pain
.

Answer 23

Answer: C.

Rationale: Intractable pain is a type of chronic pain that persists despite various treatment approaches and is particularly challenging to manage

Question 24

A patient is scheduled for a painful procedure. When should the nurse administer a prescribed analgesic medication for optimal pain management?
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A. After the procedure, when the patient reports pain
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B. Immediately before the procedure to minimize discomfort
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C. 30 minutes before the procedure to allow for medication absorption
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D. The timing of analgesic administration is irrelevant for procedural pain.

Answer 24

Answer: C.

Rationale: Administering analgesics before a painful procedure, allowing sufficient time for medication absorption, ensures optimal pain control and reduces patient distress.

Question 25

Which nursing action is most important when administering intravenous opioid analgesics?
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A. Assess the patient’s pain level using a standardized pain scale.
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B. Monitor the patient’s respiratory rate and oxygen saturation levels.
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C. Document the patient’s response to the medication administration.
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D. Educate the patient on the potential side effects of opioid medications.

Answer 25

Answer: B.

Rationale: Opioid medications can cause respiratory depression. Monitoring respiratory rate and oxygen saturation is crucial for patient safety. While other actions are important, respiratory monitoring takes precedence

Question 26

Which statement reflects a common misconception about pain management?
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A. Pain is a subjective experience and varies among individuals.
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B. Patients with a history of addiction should not receive opioid analgesics.
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C. Nonpharmacological interventions can be effective in managing pain.
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D. Regular pain assessment is essential for effective pain management.

Answer 26

Answer: B.

Rationale: Patients with a history of addiction still require adequate pain relief. Careful assessment, monitoring, and collaboration with pain specialists and addiction counselors are essential when managing pain in these patients.

Question 27

What is the primary goal of pain management?
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A. To eliminate all pain, regardless of the cause
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B. To reduce pain to a level acceptable to the patient
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C. To prevent the development of dependence on pain medication
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D. To minimize the use of pharmacological interventions

Answer 27

Answer: B.

Rationale: Pain management aims to reduce pain to a level that the patient finds tolerable, allowing them to participate in activities and maintain an acceptable quality of life. Complete pain elimination may not always be achievable

Question 28

A patient is prescribed a nonsteroidal anti-inflammatory drug (NSAID) for pain relief. Which factor in the patient’s medical history would contraindicate the use of NSAIDs?
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A. History of asthma
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B. History of peptic ulcer disease
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C. History of hypertension
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D. History of diabetes mellitus

Answer 28

Answer: B.

Rationale: NSAIDs can increase the risk of gastrointestinal bleeding, making them contraindicated in patients with a history of peptic ulcer disease.

Question 29

Which statement accurately describes the concept of equianalgesia?
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A. All opioid analgesics have the same potency and produce equal pain relief.
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B. Different opioid analgesics can provide similar pain relief at varying doses.
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C. Nonopioid analgesics are equally effective as opioid analgesics for severe pain.
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D. The route of analgesic administration does not affect the level of pain relief.

Answer 29

Answer: B.

Rationale: Equianalgesia refers to the concept that different opioids can provide comparable pain relief at different doses. This principle is crucial when switching between opioid medications or routes of administration.

Question 30

Which ethical principle is most important for the nurse to consider when managing a patient’s pain?
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A. Beneficence, the duty to do good
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B. Autonomy, the patient’s right to self-determination
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C. Justice, the fair allocation of resources
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D. Nonmaleficence, the duty to avoid harm

Answer 30

Answer: A.

Rationale: Beneficence, the ethical principle of doing good, underscores the nurse’s obligation to provide adequate pain relief and advocate for the patient’s well-being.