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A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client is to the client. The nurse issues the client is to the possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
- A. Being able to sleep dosent means pain doesit exist.
- B. Have you ever experienced any type of pain?
- C. The client should be assessed for drugg addiction.
- D. Your right right I would pain the medication back.
Correct Answer: A
Rationale: A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain cited. Physiologic changes due to pain vary from the client to client, and assessments of pain should not supervised the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippain, and does not provide useful information. This amount of information does not be the client is to the client.
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A nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect on location, quality, intensity, effect on location, quality, intensity, effect on... [incomplete question]. What is the next best step for the nurse to take?
- A. Document the findings and continue monitoring
- B. Administer pain medication immediately
- C. Consult with the physician for further orders
- D. Reassess the client's pain after 30 minutes
Correct Answer: A
Rationale: The nurse has gathered initial pain assessment data. The next best step is to document the findings and continue monitoring to track changes in the client's pain status. Administering medication without further evaluation or consulting the physician prematurely may not be appropriate, and reassessing after a set time may delay necessary interventions.
Which client should the nurse see first?
- A. Client being discharged lane on a complicated analgesia regimen
- B. Client with new-onset abdominal pain, rated as an 8 on a 6-to 10 scale
- C. Client who has returned from physical therapy and is resting in the redliner
- D. Client who is requesting additional pain medication
Correct Answer: B
Rationale: Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes as an hour for the oral medication. The client needs and should be a time during to assess for effectiveness. The client going home reporting teaching, which should be done after the first two clients have been seen and cared for this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching and done to being going.
A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include to the clients care plan?
- A. Pre-needed pain medication after therapy
- B. Pain medication is more consumers and more rate
- C. Pain medications prior to therapy only
- D. Round-the-clock analgesia with PRN analgesics.
Correct Answer: D
Rationale: Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain related to specific procedures is managed with additional medication. Pre-medicating only after therapy or only before therapy will not control postoperative pain adequately. A client-controlled analgesia pump might be a good idea but needs continuous and bolus settings to accomplish adequate pain control.
A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
- A. Assess pain physiological indicators and vital signs.
- B. Do not give pain medication as no pain is indicated.
- C. To present the findings and continue to monitor.
- D. Try a human state of analgesic medication for pain.
Correct Answer: A
Rationale: Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain, he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.
A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?
- A. Assess and record the client every hour
- B. Have another nurse double-check the PCA pump settings
- C. Instruct the client to report any unrelieved pain
- D. Monitor for numbness and tingling in the legs
Correct Answer: B
Rationale: Epidural analgesia poses risks, and pump settings must be accurate to prevent overdose or underdose. Having another nurse double-check the settings is critical for safety. Frequent assessments, reporting unrelieved pain, and monitoring for numbness are important but secondary to ensuring correct pump settings.