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What action should the nurse implement when assisting a postoperative patient with pain control and comfort?
- A. Pull the patient up in bed.
- B. Lift the patient up in bed.
- C. Tighten constricting bandages.
- D. Restrict fluid and dietary intake.
Correct Answer: B
Rationale: Pain control and comfort measures include loosening constricting bandages, lifting, not pulling the patient up in bed, and preventing constipation by encouraging appropriate fluid and dietary intake.
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The nurse explains that transcutaneous electric nerve stimulation provides a continuous mild electric current to the skin. How does the TENS unit act to reduce pain?
- A. Distracts the patient.
- B. Blocks endorphin production.
- C. Warms the skin.
- D. Blocks pain impulses.
Correct Answer: D
Rationale: TENS works by blocking pain impulses.
A patient is receiving epidural analgesics. What should the nurse monitor closely in this patient?
- A. Temperature elevation from 98°F to 99.2°F (36.6°C to 37.3°C)
- B. Increase in pulse rate from 88 to 99
- C. Decrease in respirations from 16 to 14
- D. Decrease in blood pressure from 120/80 to 110/68
Correct Answer: C
Rationale: Administering epidural analgesics requires close monitoring for respiratory depression. None of the other options is indicative of opiate toxicity.
Which documentation sample is the most helpful to share assessment findings and pain relief interventions?
- A. 1600: Patient reports chest pain. Medicated with morphine sulfate.
- B. 1600: Patient reports sharp chest pain. Morphine sulfate given IM.
- C. 1600: Patient reports sharp pain in left chest radiating to neck. Morphine sulfate 5 mg administered IM in right deltoid.
- D. 1600: Patient requested medication for pain in left chest. Morphine sulfate 10 mg PO given.
Correct Answer: C
Rationale: The nurse should record subjective information relative to the pain, as well as the intervention and administration route.
A patient is receiving an opioid narcotic. What common side effect should the nurse be aware of when assessing this patient?
- A. Addiction
- B. Vomiting
- C. Constipation
- D. Diarrhea
Correct Answer: C
Rationale: Constipation is the most common opioid narcotic side effect for which patients do not develop a tolerance.
A patient tearfully declares the use of relaxation techniques does not work for her. What is the best action for the nurse to implement?
- A. Give up on the idea.
- B. Encourage the patient to try again.
- C. Assure the patient that not everyone is successful.
- D. Give the patient a sedative.
Correct Answer: B
Rationale: Some alternative approaches to pain control require practice. Encouragement to try again is appropriate.