Week 7 sherpath

Question 1

Which cues would the nurse use to determine a patient’s safety needs?

Select all that apply.

Subjective data related to the patient’s symptoms

Patient’s family history

Subjective information about the patient’s chief complaint

Patient’s history of exposures to environmental hazards

Objective assessment focused on the affected body systems

Answer 1

Subjective data related to the patient’s symptoms

Subjective information about the patient’s chief complaint

Patient’s history of exposures to environmental hazards

Objective assessment focused on the affected body systems

Question 2

To specifically assess the patient’s safety risks related to health issues, which question would the nurse ask?

What safety concerns do you have?

Have you ever had a seizure?

Who else lives with you?

Do you require assistance with bathing?

Answer 2

Have you ever had a seizure?

Question 3

Which question would the nurse ask to assess a patient’s understanding of the risks of chemicals?

Where do you store your household cleaners?

Do you know why you take your current set of medications?

Are separate cutting surfaces used for cutting raw fish and meats?

Do you have any safety concerns at home or work?

Answer 3

Where do you store your household cleaners?

Question 4

Educating patients about electrical cord safety is important in preventing which specific home safety hazard?

Fire

Outdoor safety hazards

Carbon monoxide poisoning

Biohazards

Answer 4

Fire

Question 5

To assess the patient’s risk for exposure to biohazards in the home, which question would the nurse ask?

Do you have air conditioning?

What recreational activities do you engage in?

Is there adequate outside lighting?

Do you or does anyone in the home use hypodermic needles?

Answer 5

Do you or does anyone in the home use hypodermic needles?

Question 6

Which member of the interprofessional team would the nurse consult to evaluate a patient for safe performance of activities of daily living (ADLs)?

Social worker

Physical therapist

Occupational therapist

Unlicensed assistive personnel

Answer 6

Occupational therapist

Question 7

Which member of the interprofessional team would the nurse consult to evaluate a patient who is a fall risk?

Health care provider

Physical therapist

Occupational therapist

Unlicensed assistive personnel

Answer 7

Physical therapist

Question 8

During an assessment, the nurse learns that a patient and child are living in a car. Which member of the interprofessional team would the nurse consult with to evaluate these individuals?

Health care provider

Social worker

Physical therapist

Occupational therapist

Answer 8

Social worker

Question 9

A fire prevention plan must include changing batteries in smoke alarms (detectors) at least every

___ months.

Answer 9

6 months

Question 10

Many hospitals use the acronym RACE to describe emergency fire response. Which terms stand for the letters in RACE?

Rescue, Advise, Comfort, Expedite

Rescue, Alarm, Contain, Extinguish

Restrain, Action, Continue, Emergency

Resuscitate, Action, Control, Emergency

Answer 10

Rescue, Alarm, Contain, Extinguish

Question 11

Which action would the nurse take first when discovering a fire in a patient’s room?

Extinguish the fire.

Contain the fire.

Remove the patient from the room.

Sound the alarm

Answer 11

Remove the patient from the room.

Question 12

The nurse is caring for a 72-year-old patient who is on bed rest after hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. Upon assessment, the nurse notes an intravenous (IV) infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient’s total score?

Answer 12

75

Question 13

The nurse is asking the patient a series of questions about the patient’s activities of daily living. The patient asks the nurse why that information is important. Which nursing response is appropriate?

“The answers to these questions will help us determine if you need any assistance at home.”

“This information will help your health care provider determine if you need to be placed in a skilled nursing facility.”

“The questions are designed to get you to think about going home from the hospital.”

“This is part of our regular patient assessment form that we must complete.”

Answer 13

“The answers to these questions will help us determine if you need any assistance at home.”

Question 14

A patient is on a large number of medications, and the nurse is concerned about the patient’s personal ability to manage taking all the medications at home. Which questions would the nurse ask to assess the patient’s potential safety risk?

Select all that apply.

“Do you take your medications consistently?”

“Do any young children live in the home who know about - your medications?”

“Do you know how to take these prescriptions?”

“Do you know when to take your drugs?”

“Do you know why the health care provider has prescribed these medications?”

Answer 14

Do you take your medications consistently?”

“Do you know how to take these prescriptions?”

“Do you know when to take your drugs?”

“Do you know why the health care provider has prescribed these medications?”

Question 15

A patient with paraplegia is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment?

“Do you have a carbon monoxide detector?”

“Do you have a plan to exit the home in case of an emergency?”

“Where are your medications stored?”

“Do you have a fire extinguisher?”

Answer 15

“Do you have a plan to exit the home in case of an emergency?”

Question 16

Which factor is a patient-related fall risk hazard?

Wound drain

Floor surfaces

Intravenous access

Incontinence

Answer 16

Incontinence

Question 17

The nurse is planning care for a patient who is 70 years old, lives at home with her healthy 50-year-old daughter, and swims and walks daily. When the patient says she wants to learn more about staying safe at home, which need would the nurse identify as the priority?

Fall prevention

Drowning precautions

Preventing methicillin-resistant Staphylococcus aureus (MRSA)

Avoidance of hypothermia

Answer 17

Fall prevention

Question 18

A 90-year-old patient taking multiple medications is being discharged to home. Which members of the interprofessional team would the nurse consult with to evaluate fall risk?

Select all that apply.

Pharmacist

Social worker

Physical therapist

Unlicensed assistive personnel

Occupational therapist

Answer 18

Pharmacist

Physical therapist

Occupational therapist

Question 19

The nurse identifies that a patient has difficulty putting on shoes and buttoning a shirt after the examination. Which goal would the nurse create as part of the plan of care?

Patient will select appropriate clothing to wear.

Patient will put on shoes and button shirt.

Patient will perform own activities of daily living (ADLs).

Patient will dress self within 1 month.

Answer 19

Patient will dress self within 1 month.

Question 20

The nurse is educating a patient about home safety. Which patient response indicates that further nursing teaching is required?

“My electrical outlets have covers on them.”

“I shave with my electric razor when I am in the tub for convenience.”

“There is a fire extinguisher in the kitchen.”

“I have smoke detectors in each room.”

Answer 20

“I shave with my electric razor when I am in the tub for convenience.”

Question 21

The nurse is admitting a patient who is a fall risk. Which room will the nurse assign?

Room at the end of the hallway

Room nearest the nurses’ station

Double room with a roommate

Room in the middle of the hallway

Answer 21

Room nearest the nurses’ station

Question 22

The nurse is evaluating a patient’s understanding of home safety measures. Which patient response indicates that teaching has been effective?

“I checked my floorboards to make sure they are even.”

“I only need to use my cane when I leave the house.”

“I don’t like night-lights because they keep me awake.”

“I throw my used diabetic needles into a soda can when I am done with them.”

Answer 22

“I checked my floorboards to make sure they are even.”

Question 23

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed?

Place the patient on complete bed rest.

Initiate a fall prevention plan for the patient.

Start passive range-of-motion exercises twice a day.

Make sure the patient only ambulates with a walker.

Answer 23

Initiate a fall prevention plan for the patient.

Question 24

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Allow the patient to dangle.

Stand the patient up with assistance.

Transfer the patient with a slide board.

Place the transfer belt after the patient stands

Answer 24

Allow the patient to dangle.

Question 25

Match each type of exercise to its example.

Ambulating

Kegel exercises

Heavy weight-lifting

Repeated stair-climbing

Answer choices

Isotonic

Anaerobic

Isometric

Aerobic

Answer 25

Ambulating
Isotonic

Kegel exercises
Isometric

Heavy weight-lifting
Anaerobic

Repeated stair-climbing
Aerobic

Question 26

Which interventions would the nurse implement for a patient with lower extremity Paralysis?

Select all that apply.

Apply oxygen.

Turn every 2 hours.

Arrange for a special bed.

Use a gait belt for transfers and ambulation.

Perform range-of-motion (ROM) exercises at least two times per day.

Answer 26

Turn every 2 hours.

Arrange for a special bed.

Perform range-of-motion (ROM) exercises at least two times per day.

Question 27

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving?

Ambulates 15 feet with shortness of breath

Has a heart rate of 110 beats/min when ambulating

Brushes hair while sitting in chair with assistance

Has a pulse oximetry reading of 94% when standing to brush teeth

Answer 27

Has a pulse oximetry reading of 94% when standing to brush teeth

Question 28

Which instruction would the nurse share with the patient about coughing techniques?

Fully inhale between coughs.

Take two deep breaths in and out to start.

Inhale through the nose as deeply as possible.

Exhale slowly through the spirometer’s mouthpiece.

Answer 28

Take two deep breaths in and out to start.

Question 29

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)?

Ensure the fit of the sleeves is tight.

Roll the sleeves inside out to apply them.

Activate the heating feature once a shift.

Monitor the patient’s toes for impaired circulation.

Answer 29

Monitor the patient’s toes for impaired circulation.

Question 30

Which action would the nurse take to improve an immobile patient’s nutritional intake?

Monitor the patient’s serum albumin.

Assess the patient’s nutritional intake.

Allow the patient to make food choices.

Weigh the patient at routine intervals.

Answer 30

Allow the patient to make food choices.

Question 31

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining?

Select all that apply.

Has a reddened area on hip that will not blanch

Has dry, warm, intact skin

Has a Braden Scale score that indicates a high risk for skin breakdown

Develops a Stage 1 pressure injury on the buttocks

Develops a Stage 2 pressure injury on the left hip

Answer 31

Has a Braden Scale score that indicates a high risk for skin breakdown

Develops a Stage 1 pressure injury on the buttocks

Develops a Stage 2 pressure injury on the left hip

Question 32

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle?

Encourage contact with family and friends.

Provide a clock in the patient’s room.

Open the window blinds during the day.

Allow access to the radio.

Answer 32

Open the window blinds during the day.

Question 33

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity?

Dietitian

Primary health care provider

Occupational therapist

Unlicensed assistive personnel

Answer 33

Unlicensed assistive personnel

Question 34

In which area would the nurse place a pillow for a patient in the supine position?

Between the legs

Under the calves

Between the arms

Under the scapula

Answer 34

Under the calves

Question 35

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed?

Trapeze bar

Mechanical lift

Transfer board

Friction-reducing sheet

Answer 35

Trapeze bar

Question 36

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation?

Cane

Walker

Crutches

Trochanter roll

Answer 36

Walker

Question 37

Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement?

Improves mood

Minimizes joint flexibility

Promotes muscle strength

Stimulates bone reabsorption

Answer 37

Promotes muscle strength

Question 38

In which position would the nurse place the patient to perform coughing and deep breathing?

Dorsal recumbent

Fowler’s

Side-lying

Sim’s

Answer 38

Fowler’s

Question 39

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility?

Ensures that no more than 35 lb (15.9 kg) is placed in the lift

Has the patient grab the bars for stability

Transfers the patient toward the weaker side

Obtains two unlicensed assistive personnel to help

Answer 39

Obtains two unlicensed assistive personnel to help

Question 40

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

Place the patient flat in bed.

Encourage the patient to take deep breaths.

Assess the patient for signs of deep vein thrombosis.

Notify the health care provider that the patient may have pneumonia.

Answer 40

Notify the health care provider that the patient may have pneumonia.

Question 41

Which action would the nurse take for a patient on bed rest who is concerned about developing constipation?

Increase the patient’s dietary fiber and fluid intake.

Complete the Braden Scale assessment tool.

Increase the frequency of passive range-of-motion exercises.

Administer enoxaparin prophylactically.

Answer 41

Increase the patient’s dietary fiber and fluid intake.

Question 42

Which interventions would the nurse select for a patient who is on bed rest?

Select all that apply.

Have the patient shift weight every 15 minutes while awake.

Have the unlicensed assistive personnel teach about the importance of mobility.

Reduce hallway light at night.

Apply a pressure-relief ankle-foot orthotic (PRAFO) boot.

Turn patient every 4 hours.

Answer 42

Have the patient shift weight every 15 minutes while awake.

Reduce hallway light at night.

Apply a pressure-relief ankle-foot orthotic (PRAFO) boot.

Question 43

Which actions would the nurse take for a patient who is immobile?

Select all that apply.

Encourage at least 1500 mL of fluid daily.

Suggest drinking at least 2000 mL during a 24-hour period.

Encourage passive range-of-motion exercises.

Place high-top tennis shoes on feet.

Reposition at least once every 8 hours.

Answer 43

Suggest drinking at least 2000 mL during a 24-hour period.

Encourage passive range-of-motion exercises.

Place high-top tennis shoes on feet.

Question 44

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility?

Select all that apply.

Use the incentive spirometer 5 to 12 times every 1 to 2 hours.

Deep breathe 10 times every hour.

Cough two to three times every 2 hours.

Perform range-of-motion exercises at least five to six times each day.

Move each joint three to five times during range-of-motion exercises.

Answer 44

Use the incentive spirometer 5 to 12 times every 1 to 2 hours.

Deep breathe 10 times every hour.

Cough two to three times every 2 hours.

Move each joint three to five times during range-of-motion exercises.

Question 45

Which safety measures would the nurse implement for a patient who is a fall risk?

Select all that apply.

Use a low bed.

Place in a room away from the nurses’ station for quietness.

Raise all four side rails.

Frequently orient the patient.

Place floor mats beside the bed.

Answer 45

Use a low bed.

Frequently orient the patient.

Place floor mats beside the bed.

Question 46

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse?

Select all that apply.

Refuses to massage a patient’s leg with deep vein thrombosis

Places a gait belt on a patient with osteoporosis to assist with ambulation

Allows the patient’s elbows to be bent at a 45-degree angle when using a cane

Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg

Has the patient cough two times after using an incentive spirometer

Answer 46

Places a gait belt on a patient with osteoporosis to assist with ambulation

Allows the patient’s elbows to be bent at a 45-degree angle when using a cane

Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg

Question 47

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating?

Select all that apply.

Experiences a pulmonary embolus

Has dusky toes

Has coagulation laboratory results that indicate the patient is clotting too fast

States the sequential compression device pressure is maintained at 40 mm Hg

Experiences intact skin with no abnormalities in the lower leg

Answer 47

Experiences a pulmonary embolus

Has dusky toes

Has coagulation laboratory results that indicate the patient is clotting too fast

Question 48

Which cues alert the nurse that the patient with Paralysis is declining?

Select all that apply.

Develops disuse osteoporosis

Has not lost muscle mass

Does not participate in physical therapy

Controls wheelchair according to capabilities

Avoids muscle atrophy

Answer 48

Develops disuse osteoporosis

Does not participate in physical therapy

Question 49

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving?

Select all that apply.

Needs a one-person assist to ambulate

Needs no assistance to transfer

Ambulates unassisted down the corridor and back

Needs a two-person assist to walk to the bathroom

Ambulates with no slips on the floor

Answer 49

Needs no assistance to transfer

Ambulates unassisted down the corridor and back

Ambulates with no slips on the floor

Question 50

Which actions would the nurse take if the patient falls while ambulating in the hall?

Select all that apply.

Call for help.

Assess the patient’s physical and neurologic status.

Notify charge nurse and primary health care provider.

Leave the patient to go get help.

Complete occurrence report.

Answer 50

Call for help.

Assess the patient’s physical and neurologic status.

Notify charge nurse and primary health care provider.

Complete occurrence report.

Question 51

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient?

Select all that apply.

Leave top side rails up.

Bend at the knees.

Carry weight close to the body.

Use mechanical lift equipment.

Relax pelvic muscles.

Answer 51

Leave top side rails up.

Bend at the knees.

Carry weight close to the body.

Use mechanical lift equipment.

Question 52

The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number.

Answer 52

2 hours

Question 53

Place the steps in the order the nurse would follow to teach a patient how to use a cane.

Move the stronger leg.

Move the weaker leg.

Place cane on the patient’s stronger side.

Move the cane.

Answer 53

Place cane on the patient’s stronger side.

Move the cane.

Move the weaker leg.

Move the stronger leg.

Question 54

Which aspects would the nurse consider when conducting a pain assessment for a patient in a non–life-threatening situation?

Select all that apply.

Health literacy does not influence the assessment.

The nurse should complete the assessment as quickly as possible.

The patient’s values and beliefs about pain affect the assessment.

The nurse’s values and beliefs about pain may influence the assessment.

A calm and supportive manner promotes effective communication.

Answer 54

The patient’s values and beliefs about pain affect the assessment.

The nurse’s values and beliefs about pain may influence the assessment.

A calm and supportive manner promotes effective communication.

Question 55

Which scenario describes when a nurse would perform a focused pain assessment on a patient?

Anytime a patient is at high risk for pain

Before taking vital signs and the patient reports the pain is mild

After taking vital signs and the patient reports the pain is mild

After taking vital signs and the patient reports the pain is severe

Answer 55

After taking vital signs and the patient reports the pain is severe

Question 56

Which pain assessment tools utilize verbal reports from the patient?

Select all that apply.

0–10 Pain Scale

Neonatal Infant Pain Scale

Universal Pain Tool

Wong-Baker Scale

Pain Assessment in Advanced Dementia Scale

Answer 56

0–10 Pain Scale

Universal Pain Tool

Wong-Baker Scale

Question 57

Which technology innovations can the nurse use to accurately assess or manage pain?

Select all that apply.

Informatics

Pharmacogenomics

Neuroimaging biomarkers

Noncognitive assessment tools

Magnetic resonance imaging

Answer 57

Informatics

Pharmacogenomics

Neuroimaging biomarkers

Magnetic resonance imaging

Question 58

Match the body system to the associated physiologic alteration caused by pain.

Decreases air exchange

Increases oxygen demand

Develops spasms, tension, and fatigue

Releases hormones such as cortisol, glucagon, and insulin

Answer choices

Cardiovascular

Respiratory

Endocrine

Muscular

Answer 58

Decreases air exchange
Respiratory

Increases oxygen demand
Cardiovascular

Develops spasms, tension, and fatigue
Muscular

Releases hormones such as cortisol, glucagon, and insulin
Endocrine

Question 59

Match the body system to the associated physiologic alteration caused by pain.

Decreases motility and emptying

Releases inflammatory mediators

Increases blood pressure through release of hormones

Answer choices

Urinary

Gastrointestinal

Immune

Answer 59

Decreases motility and emptying
Gastrointestinal

Releases inflammatory mediators
Immune

Increases blood pressure through release of hormones
Urinary

Question 60

Which cue would the nurse anticipate when assessing a patient experiencing pain?

Diarrhea

Indigestion

Weight gain

Increased bowel sounds

Answer 60

Indigestion

Question 61

Which cues are behavioral indications of pain?

Select all that apply.

Fear

Moaning

Agitation

Depression

Clenching teeth

Answer 61

Moaning

Agitation

Clenching teeth

Question 62

Which aspects reflect key considerations for the nurse to effectively recognize cues related to pain?

Select all that apply.

Culture

Urgency

Relevance

Physiology

Importance

Answer 62

Urgency

Relevance

Importance

Question 63

Which action allows the nurse to begin collecting cues about a burn patient’s pain experience?

Performing comfort measures

Taking the patient’s vital signs

Recording the patient’s meal order

Removing the dressings to assess the wound

Answer 63

Taking the patient’s vital signs

Question 64

Which questions would the nurse ask when conducting a pain assessment for a trauma patient?

Select all that apply.

“Where is the pain located?”

“Where did the trauma occur?”

“What makes the pain worse or better?”

“Does the pain radiate anywhere?”

“On a scale from 1 to 50, how would you rate your pain?”

Answer 64

“Where is the pain located?”

“What makes the pain worse or better?”

“Does the pain radiate anywhere?”

Question 65

A nurse is conducting a pain assessment using the SOCRATES acronym. Which concept reflects the meaning of the letter “T” in SOCRATES?

Time course

Type of pain

Temperature

Time of onset

Answer 65

Time course

Question 66

The nurse assesses the patient’s pain using the SOCRATES acronym. Which additional question would be relevant to the pain assessment?

“Where is the pain located?”

“Is the pain stabbing, burning, or aching?”

“Does anything make the pain worse or lessen it?”

“What are your past pain experiences?”

Answer 66

“What are your past pain experiences?”

Question 67

The nurse working in an urgent care office assesses a patient who presents with a possible broken ankle that is edematous. The patient rates the pain a 9 on a 0–10 scale. The nurse obtains vital signs and notices that the patient grimaces every time the affected foot moves. Which cue reflects subjective data?

Vital signs

Edematous ankle

Weak pulse in the foot

Pain rating of 9 on a 0–10 scale

Answer 67

Pain rating of 9 on a 0–10 scale

Question 68

The nurse asks a patient experiencing painful kidney stones to rate the pain on a scale from 0 to 10. The patient rates the pain as a 7. Which phrase describes the patient’s level of pain indicated by the rating?

Mild pain

Severe pain

Average pain

Moderate pain

Answer 68

Severe pain

Question 69

Which statement reflects how the gastrointestinal system responds to pain?

Releases extra gas

Speeds metabolism

Increases gastric emptying

Decreases intestinal motility

Answer 69

Decreases intestinal motility

Question 70

Which statement describes how pain experienced by postoperative patients increases the risk for development of pneumonia?

Inhibits the inflammatory response

Causes a reluctance to breathe deeply

Increases mucus as a result of emotional reaction and crying

Releases insulin, causing diabetes and decreased oxygenation

Answer 70

Causes a reluctance to breathe deeply

Question 71

Which patient cues are indicative of chronic pain?

Select all that apply.

Dilated pupils

Constricted pupils

Increased heart rate

Decreased heart rate

Increased systolic blood pressure

Decreased systolic blood pressure

Answer 71

Constricted pupils

Decreased heart rate

Decreased systolic blood pressure

Question 72

A patient with diabetes presents at the emergency department with a broken arm and pain rated 8 on a 0–10 pain scale. Which effect on the patient’s blood glucose would be anticipated?

Increased blood glucose level

Decreased blood glucose level

Fluctuating blood glucose level

No effect on blood glucose level

Answer 72

Increased blood glucose level

Question 73

Which cue reflects that the patient is experiencing pain?

Hypoglycemia

Decreased urine output

Reduced respiratory rate

Loose bowel movements

Answer 73

Decreased urine output

Question 74

Which cues are psychological expressions of pain?

Select all that apply.

Fear

Crying

Agitation

Depression

Helplessness

Facial grimacing

Answer 74

Fear

Depression

Helplessness

Question 75

Which cues are relevant to the adult patient’s acute pain experience?

Select all that apply.

Dilated pupils

Heart rate of 120

Respiratory rate of 12

Blood pressure of 118/62

Pain rated 7 on 0–10 pain scale

Answer 75

Dilated pupils

Heart rate of 120

Pain rated 7 on 0–10 pain scale

Question 76

Which actions support the nurse’s role in pain management?

Select all that apply.

Assessing the patient’s pain level

Educating the patient about pain relief options

Evaluating patient response to pain interventions

Using medication as the primary treatment for pain management

Advocating with the health care provider for pain relief for the patient

Answer 76

Assessing the patient’s pain level

Educating the patient about pain relief options

Evaluating patient response to pain interventions

Advocating with the health care provider for pain relief for the patient

Question 77

Which statements reflect The Joint Commission’s (TJC’s) pain assessment standards?

Select all that apply.

Document the comprehensive pain assessment.

Provide nonpharmacologic pain treatment modalities.

Address pain assessment and management with new staff.

Develop an evidence-based and standardized pain treatment plan.

Monitor patients at high risk for adverse outcomes related to opioid treatment.

Answer 77

Provide nonpharmacologic pain treatment modalities.

Address pain assessment and management with new staff.

Monitor patients at high risk for adverse outcomes related to opioid treatment.

Question 78

Match the nursing action to the related descriptive statement.

Look for adverse effects of prescribed medication.

Share information about potential adverse effects and usages.

Consider the effectiveness of pain management interventions.

Provide clear documentation in the patient’s record.

Answer choices

Assess

Communicate

Evaluate

Educate

Answer 78

Look for adverse effects of prescribed medication.
Assess

Share information about potential adverse effects and usages.
Educate

Consider the effectiveness of pain management interventions.
Evaluate

Provide clear documentation in the patient’s record.
Communicate

Question 79

Which actions are considered nonpharmacologic pain management interventions the nurse can perform without a prescription from a health care provider?

Select all that apply.

Patient repositioning

Using distraction techniques

Educating about opioid dependence

Postoperative splinting

Using progressive relaxation techniques

Answer 79

Patient repositioning

Using distraction techniques

Postoperative splinting

Using progressive relaxation techniques

Question 80

Match the nonpharmacologic therapies with the appropriate description.

Has pain-relieving properties

Restores a calm state, promoting relaxation

Helps build strength, and balance body and mind

Trains the body for voluntary control to relieve pain

Answer choices

Meditation

Biofeedback

Yoga

Herbs

Answer 80

Has pain-relieving properties
Herbs

Restores a calm state, promoting relaxation
Meditation

Helps build strength, and balance body and mind
Yoga

Trains the body for voluntary control to relieve pain
Biofeedback

Question 81

Which traditional Chinese therapy is often associated with nonpharmacologic pain relief?

Massage

Hypnosis

Acupuncture

Nerve stimulation

Answer 81

Acupuncture

Question 82

Which pain management strategy is a neurologic therapy?

Distraction

Positioning

Nerve stimulation

Massage therapy

Answer 82

Nerve stimulation

Question 83

Which statement describes multimodal analgesia?

Two or more medications are used to relieve pain.

More than one intervention is used to control pain.

Pain medication is used in anticipation of a painful event.

Pharmacologic and nonpharmacologic strategies are combined.

Answer 83

Two or more medications are used to relieve pain.

Question 84

Which characteristic of non-opioid analgesic medications describes why nurses administer them more often than opioid analgesics?

Easier to dispense

Safer for the patient

Cheaper to dispense

Prescription not required

Answer 84

Safer for the patient

Question 85

Which statement describes a benefit of patient-controlled analgesia (PCA)?

Patients can self-administer and manage their pain medication.

Patients’ families can administer medication whenever desired.

Patients can give themselves as much medication as they desire.

The nurse does not have to perform a check before administration.

Answer 85

Patients can self-administer and manage their pain medication.

Question 86

Which statement by the new nurse indicates understanding of the nurse’s role in pain management?

Select all that apply.

“I will be sure to educate the patient about pain treatment options.”

“I will remember to assess for pain as a part of my initial assessment.”

“I will perform a cardiac assessment to complete proper pain management procedures.”

“I must advocate for adequate pain relief for my patient if current therapies seem - ineffective.”

“I must evaluate the patient’s response to interventions to deliver focused patient care.”

Answer 86

“I will be sure to educate the patient about pain treatment options.”

“I will remember to assess for pain as a part of my initial assessment.”

“I must advocate for adequate pain relief for my patient if current therapies seem - ineffective.”

“I must evaluate the patient’s response to interventions to deliver focused patient care.”

Question 87

Which statement reflects the purpose of the Rights of Medication Administration?

Facilitate the discharge process

Prevent medication errors

Increase patient satisfaction scores

Aid the health care provider in prescribing the correct medication

Answer 87

Prevent medication errors

Question 88

The nurse tells a patient that oxycodone can cause itchiness and sleepiness and that it must be taken only as prescribed. The nurse also recommends taking a stool softener with this medication as it may cause constipation. Which action is the nurse demonstrating?

Education

Evaluation

Assessment

Intervention

Answer 88

Education

Question 89

The health care provider prescribes an oral analgesic every 4 hours as needed for pain. At hour 3, the patient still complains of severe pain rated 8 on a 0–10 scale and verbalizes feelings of frustration as a result of lack of pain relief. Which action is most effective for the nurse to take while awaiting a prescription for an increase in pain medication?

Telling the patient to try to relax and rest

Turning on the TV to provide a distraction for the patient

Implementing massage and positioning techniques

Conversing with the patient to draw attention away from the pain

Answer 89

Implementing massage and positioning techniques

Question 90

A patient who is in labor reports intense, painful contractions and feels very nauseous. The patient wants to proceed without the use of medication. Which nonpharmacologic interventions can the nurse implement for this patient?

Select all that apply.

Repositioning the patient

Massaging the patient’s back

Assisting with deep breathing exercises

Consulting with the patient’s birthing doula

Keeping the patient hydrated with clear liquids

Answer 90

Repositioning the patient

Massaging the patient’s back

Assisting with deep breathing exercises

Question 91

A patient is 2 days post–knee surgery. The pain management plan includes pharmacologic treatment, but the patient also requests nonpharmacologic methods, so the nurse brings the patient an ice pack. Which statement by the nurse indicates an understanding of the use of cold therapy to treat pain?

“Thermotherapy provides local analgesia.”

“Ice packs should be applied for up to 1 hour.”

“Rest periods from cold therapy should be provided to prevent tissue injury.”

“Cryotherapy is effective for pain management because it speeds nerve conduction.”

Answer 91

“Rest periods from cold therapy should be provided to prevent tissue injury.”

Question 92

A patient who presents to the emergency department with mild leg strain requests nonpharmacologic pain treatment. Which alternative therapies would the nurse suggest?

Select all that apply.

Yoga

Aspirin

Exercise

Meditation

Biofeedback

Answer 92

Yoga

Meditation

Biofeedback

Question 93

A patient has a broken femur and is in excruciating pain. The health care provider prescribes an intravenous opioid and acetaminophen combination for pain relief. Which statement explains why the two medications are prescribed for pain?

Select all that apply.

The mixture of medications produces fewer side effects.

Multimodal analgesia requires lower doses for effective pain relief.

The health care provider wants to avoid an unhappy patient call later complaining of unrelieved pain.

The combination of medications is more effective than just the opioid alone.

The choices of medications allow the nurse to select the best option based on patient preference.

Answer 93

The mixture of medications produces fewer side effects.

Multimodal analgesia requires lower doses for effective pain relief.

The combination of medications is more effective than just the opioid alone.

Question 94

A patient is prescribed a nonsteroidal antiinflammatory drug (NSAID) for arthritis. The nurse would educate the patient about which potential side effects?

Select all that apply.

Inflammation

Hepatotoxicity

Increased bleeding

Decreased heart rate

Gastrointestinal upset

Cardiac complications

Answer 94

Increased bleeding

Gastrointestinal upset

Cardiac complications

Question 95

A patient rates pain a 9 on a 0–10 scale and requests pain medication. The nurse reviews the medication administration record (MAR) and finds oxycodone, ibuprofen, acetaminophen, and ketorolac are prescribed. Which medication would the nurse administer?

Ketorolac

Ibuprofen

Oxycodone

Acetaminophen

Answer 95

Oxycodone

Question 96

The nurse gives a patient a dose of intravenous morphine for pain relief. A few minutes later, the patient’s respiratory rate is 5 breaths/min. Which medication would the nurse administer to reverse the effects of the opioid?

Naloxone

Dezocine

Fentanyl

Hydromorphone

Answer 96

Naloxone

Question 97

Which action is eliminated by the use of patient-controlled analgesia (PCA) pumps?

Assessing the patient’s pain

Requesting other types of pain medication

Educating the patient regarding pain management

Waiting for the nurse to administer pain medication

Answer 97

Waiting for the nurse to administer pain medication

Question 98

A patient is admitted to the hospital with a broken hip, and the health care provider prescribes a patient-controlled analgesia (PCA) system to manage the pain. Which patient statement reflects understanding of education about the use of PCA provided by the nurse?

“This PCA machine dispenses a pill every time I push the button.”

“I will be able to give myself pain medication any time I feel that I need it.”

“This infusion pump is programmed to give me a set dose of medication at a set time interval.”

“This infusion pump is controlled by a button, and if I can’t hit the button my family can do it for me.”

Answer 98

“This infusion pump is programmed to give me a set dose of medication at a set time interval.”

Question 99

The nurse provides literature to a patient about side effects and activities to avoid while taking a prescribed medication. Which nursing action is demonstrated when the nurse asks the patient to repeat back the information?

Analyzing

Assessing

Evaluating

Understanding

Answer 99

Assessing