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A nurse is caring for clients receiving opioid analgesics. Which actions help prevent unwanted sedation as a complication of these medications? (Select all that apply.)
- A. Avoid using other medications that cause sedation.
- B. Delay giving medication if the client is sleeping.
- C. Give the lowest dose that produces good control.
- D. Identify clients at high risk for unwanted sedation.
- E. Identify clients receiving non-opioid analgesia.
Correct Answer: A,C,D,E
Rationale: Sedation is a side effect of opioid analgesics. To prevent unwanted sedation, nurses should avoid sedative medications, use the lowest effective dose, identify high-risk clients, and monitor all clients receiving analgesia. Delaying medication for sleeping clients risks uncontrolled pain later.
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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.
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 registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?
- A. Assesses the clients pain level per agency policy
- B. Monitor the clients respiratory rate and sedation
- C. Presses the button when the client cannot reach it
- D. Reinforces client teaching about using the PCA pump
Correct Answer: C
Rationale: The client is the only person who should press the PCA button. If the client cannot reach it, the student should either question the client or adjust the button's position, not press it for the client. The other actions are appropriate.
A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?
- A. Bilateral lung crackles
- B. Bilateral lung crackles
- C. Self-reported pain of 2010
- D. Urine output of 20 ml/2 hr
Correct Answer: D
Rationale: Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to receiving ketorolac. A urine output of 20 ml/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and a pain report of 3 are not related.
A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client?
- A. Call the doctor if the Lorcet does not relieve your pain.
- B. Check any over-the-counter medications for acetaminophen.
- C. Eat more fiber and drink more water to prevent constipation.
- D. Keep your follow-up appointment with the surgeon as scheduled.
Correct Answer: B
Rationale: Advising the client to check over-the-counter medications for acetaminophen is critical to prevent exceeding the safe daily limit of 3000 mg, which could lead to hepatotoxicity. Other instructions are relevant but less critical for safety.