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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.
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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.
A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
- A. Nursing/rite pain
- B. Behavioral assessment
- C. Objective observation
- D. Client self-report
Correct Answer: D
Rationale: Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
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.
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 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.