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A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?
- A. Numeric eating angle
- B. Verbal Description Scale
- C. FACES Pain Scale-Revised
- D. Wong-Bader FACES Pain Scale
Correct Answer: C
Rationale: All nurse valid pain rating scales, however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.
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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.
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 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 on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pump. Which client should the nurse see first?
- A. Client who is presses to be sleeping soundly
- B. Client who no bolus request in 6 hours
- C. Client who is pressing the button every 10 minutes
- D. Client with a respiratory rate of a breathing rate.
Correct Answer: D
Rationale: Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates high pain levels, but the device prevents overdose. The client with no bolus request has well-controlled pain.
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.