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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.
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A nurse is preparing to give an infusion of acetaminophen (Ofirmev). The pharmacy delivers a bag containing 50 ml of normal saline and the Ofirmev. At what rate does the nurse set the IV pump to deliver this dose? (Record your answer using a whole number.) ml/hr
- A. 100 ml/hr
- B. 150 ml/hr
- C. 200 ml/hr
- D. 250 ml/hr
Correct Answer: C
Rationale: Intravenous acetaminophen (Ofirmev) is given by a 15-minute infusion. To deliver 50 ml in 15 minutes, set the IV pump for 200 ml/hr (50 ml ÷ 0.25 hr = 200 ml/hr).
A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Opioid-Induced Sedation Scale score indicating excessive sedation and oxygen saturation below 95%. What action should the nurse perform first?
- A. Apply oxygen at 2 L/min
- B. Notify the provider immediately
- C. Administer naloxone (Narcan)
- D. Encourage deep breathing exercises
Correct Answer: C
Rationale: Excessive sedation and low oxygen saturation indicate opioid-induced respiratory depression. Administering naloxone (Narcan) is the first action to reverse opioid effects and ensure client safety. Applying oxygen or notifying the provider may follow, but naloxone is the priority. Encouraging deep breathing is insufficient in this scenario.
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 student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?
- A. A multimodal approach is the preferred method of control.
- B. Doctors are much more liberal with pain medications now.
- C. Pain is so complex it takes different approaches to control it.
- D. Pain is more consumers and they demand lots of pain medicine.
Correct Answer: C
Rationale: Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best explanation.
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.