Nokea
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).
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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.
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 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.
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 hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?
- A. Assess and record the client pain every 4 hours.
- B. Ensure the client is eating a high-fiber diet.
- C. Monitor the clients bowel function every shift.
- D. Remove the old patch when applying the new one.
Correct Answer: D
Rationale: The old fentanyl patch should be removed when applying a new patch to prevent accidental overdose. The other actions are appropriate but not as critical for safety.