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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.
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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.
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.
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 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 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.