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1. You are the charge nurse. A client with


chronic pain reports to you that the nurses have
not been responding to requests for pain
medication. What is your initial action? 1. Check
the medication administration records (MARs)
and nurses notes for the past several days 2.
Ask the nurse educator to provide in-service
training about pain management 3. Perform a
complete pain assessment and take a pain
history 4. Have a conference with the nurses
responsible for the care of this client
1.1. Ans: 4 As charge nurse, you must assess
the performance and attitude of the staff in
relation to this client. After data are gathered
from the nurses, additional information can be
obtained from the records and the client as
necessary. The educator may be of assistance if
knowledge decit or need for performance
improvement is the problem. Focus:
Supervision, prioritization
2. Family members are encouraging your client
to tough out the pain rather than risk drug
addiction to narcotics. The client is stoically
abiding. You recognize that the sociocultural
dimension of pain is the current priority for the
client. Which question will you ask? 1. Where is
the pain located, and does it radiate to other
parts of your body? 2. How would you describe
the pain, and how is it affecting you? 3. What
do you believe about pain medication and drug
addiction? 4. How is the pain affecting your
activity level and your ability to function? 5.
What information do you need about pain,
healing, and addiction?
1.2. Ans: 3 Beliefs, attitudes, and familial
inuence are part of the sociocultural dimension
of pain. Location and radiation of pain address
the sensory dimension. Describing pain and its
effects addresses the affective dimension.
Activity level and function address the
behavioral dimension. Asking about knowledge
addresses the cognitive dimension. Focus:
Prioritization
3. A client with diabetic neuropathy reports a
burning, electrical-type pain in the lower
extremities that is not responding to nonsteroidal
antiinammatory drugs. The client complains
that the pain is particularly worse at night. Which
medication will you advocate for rst? 1.
Amitriptyline (Elavil) 2. Corticosteroids 3.
Hydromorphone (Dilaudid) 4. Lorazepam
(Ativan)
1.3. Ans: 1 Antidepressants such as
amitriptyline can be given to treat diabetic
neuropathy; an added benet is the sedative
effect. Corticosteroids are for pain associated
with inammation. Hydromorphone is a stronger
opioid, and it is not the rst choice for chronic
pain that can be managed with other drugs.
Lorazepam is an anxiolytic. Focus: Prioritization
4. Which client is most likely to receive opioids
for extended periods of time? 1. A client with
bromyalgia 2. A client with phantom limb pain
in the leg 3. A client with progressive pancreatic
cancer 4. A client with trigeminal neuralgia
1.4. Ans: 3 Cancecc v. r pain generally worsens
with disease progression, and the use of opioids
is more generous. Fibromyalgia is more likely to
be treated with nonopioid and adjuvant
medications. Trigeminal neuralgia is treated with
antiseizure medications such as carbamazepine
(Tegretol). Phantom limb pain usually subsides
after ambulation begins. Focus: Prioritization
5. As the charge nurse, you are reviewing the
charts of clients who were assigned to the care
of a newly graduated RN. The RN has correctly
charted dose and time of medication, but there
is no documentation regarding
nonpharmaceutical measures. What action
should you take rst? 1. Make a note in the
nurse's le and continue to observe clinical
performance 2. Refer the new nurse to the in-
service education department 3. Quiz the nurse
about knowledge of pain management 4. Give
praise for correctly charting the dose and time
and discuss the decits in charting
1.5. Ans: 4 In supervision of the new RN, good
performance should be reinforced rst and then
areas of improvement can be addressed. Asking
the nurse about knowledge of pain management
is also an option; however, it would be a more
indirect and time-consuming approach. Making
a note and watching do not help the nurse to
correct the immediate problem. In-service
training might be considered if the problem
persists. Focus: Supervision, delegation
6. In caring for a very young child with pain,
which assessment question would be the most
useful? 1. Can you point to the pain with one
nger and tell me what that pain feels like inside
of you? 2. If number 1 were a little pain and
number 10 were a big pain, what number would
your pain be? 3. The smiling face has no pain;
the crying face has a really big pain. Which one
of these several faces is like your pain? 4. One
chip is a little bit of hurt and four chips are the
most hurt. How many chips would you take for
your hurt?
1.6. Ans: 3 Pain rating scales using faces
(depicting smiling, neutral, frowning, crying, etc.)
are appropriate for young children who may
have difculty describing pain or understanding
the correlation of pain to numerical or verbal
descriptors. The other tools require abstract
reasoning abilities to make analogies and the
use of advanced vocabulary. Focus:
Prioritization
7. In application of the principles of pain
treatment, what is the rst consideration? 1.
Treatment is based on client goals. 2. A
multidisciplinary approach is needed. 3. The
client's perception of pain must be believed. 4.
Drug side effects must be prevented and
managed.
1.7. Ans: 3 The client must be believed, and his
or her experience of pain must be
acknowledged as valid. The data gathered via
client reports can then be applied to the other
options in developing the treatment plan. Focus:
Prioritization
8. Which client has the most immediate need for
intravenous (IV) access to deliver immediate
analgesia with rapid titration? 1. A client who
has sharp chest pain that increases with cough
and shortness of breath 2. A client who
complains of excruciating lower back pain with
hematuria 3. A client who is having an acute
myocardial infarction with severe chest pain 4. A
client who is having a severe migraine with an
elevated blood pressure
1.8. Ans: 3 The client with an acute myocardial
infarction has the greatest need for IV access
and is likely to receive morphine, which will
relieve pain by increasing venous capacitance.
Other clients may also need IV access for
delivery of pain medication, other drugs, or IV
uids, but the need is less urgent. Focus:
Prioritization
9. When an analgesic is titrated to manage pain,
what is the priority goal? 1. Administer the
smallest dose that provides relief with the fewest
side effects 2. Titrate upward until the client is
pain free 3. Titrate downward to prevent toxicity
4. Ensure that the dosage is adequate to meet
the client's subjective needs
1.9. Ans: 1 The goal is to control pain while
minimizing side effects. For severe pain, the
medication can be titrated upward until the pain
is controlled. Downward titration occurs when
the pain begins to subside. Adequate dosing is
important; however, the concept of controlled
dosing applies more to potent vasoactive drugs.
Focus: Prioritization
10. For client education about
nonpharmaceutical alternatives, which topic
could you delegate to an experienced LPN/LVN,
who will function with your continued support
and supervision? 1. Therapeutic touch 2.
Application of heat and cold 3. Meditation 4.
Transcutaneous electrical nerve stimulation
(TENS)
1.10. Ans: 2 Application of heat and cold is a
standard therapy with guidelines for safe use
and predictable outcomes, and an LPN/LVN will
be implementing this therapy in the hospital,
under the supervision of an RN. Therapeutic
touch requires additional training and practice.
Meditation is not acceptable to all clients, and
an assessment of spiritual beliefs should be
conducted. TENS is usually applied by a
physical therapist. Focus: Delegation
11. Which pediatric pain client should be
assigned to a newly graduated RN? 1. An
adolescent who has sickle cell disease and was
recently weaned from morphine delivered via a
patient-controlled analgesia (PCA) device to a
long-acting oral analgesic; he has been
continually asking for an increased dose. 2. A
child who is receiving palliative end-of-life care;
the child is receiving narcotics around the clock
to relieve suffering, but there is a progressive
decrease in alertness and responsiveness. 3. A
child who needs premedication before reduction
of a fracture; the child has been crying and is
resistant to any touch to the arm or other
procedures. 4. A child who has chronic pain and
whose medication and nonpharmacologic
regimen has recently been changed; the mother
is anxious to see if the new regimen is
successful.
1.11. Ans: 3 The set of circumstances is least
complicated for the child with the fracture, and
this would be the best client for a new and
relatively inexperienced nurse. The child is likely
to have a good response to pain medication,
and with gentle encouragement and pain
management the anxiety will resolve. The other
three children have more complex social and
psychologic issues related to pain management.
Focus: Delegation
12. Which client is at greatest risk for respiratory
depression while receiving opioids for
analgesia? 1. An elderly client with chronic pain
who has a hip fracture 2. A client with a heroin
addiction and back pain 3. A young female client
with advanced multiple myeloma 4. A child with
an arm fracture and cystic brosis
1.12. Ans: 4 At greatest risk are elderly clients,
opiate-naive clients, and those with underlying
pulmonary disease. The child has two of the
three risk factors. Focus: Prioritization
13. A client is crying and grimacing but denies
pain and refuses pain medication, because my
sibling is a drug addict and has ruined our lives.
What is the priority intervention for this client? 1.
Encourage expression of fears and past
experiences 2. Provide accurate information
about the use of pain medication 3. Explain that
addiction is unlikely among acute care clients 4.
Seek family assistance in resolving this problem
1.13. Ans: 1 This client has strong beliefs and
emotions related to the issue of the sibling's
addiction. First, encourage expression. This
indicates to the client that the feelings are real
and valid. It is also an opportunity to assess
beliefs and fears. Giving facts and information is
appropriate at the right time. Family involvement
is important, but it should be kept in mind that
their beliefs about drug addiction may be similar
to those of the client. Focus: Prioritization
14. A client's opioid therapy is being tapered off,
and the nurse is watchful for signs of withdrawal.
What is one of the rst signs of withdrawal? 1.
1.14. Ans: 3 Diaphoresis is one of the early
signs that occur between 6 and 12 hours after
withdrawal. Fever, nausea, and abdominal
cramps are late signs that occur between 48
Fever 2. Nausea 3. Diaphoresis 4. Abdominal
cramps
and 72 hours after withdrawal. Focus:
Prioritization
15. In the care of clients with pain and
discomfort, which task is most appropriate to
delegate to the nursing assistant? 1. Assisting
the client with preparation of a sitz bath 2.
Monitoring the client for signs of discomfort
while ambulating 3. Coaching the client to deep
breathe during painful procedures 4. Evaluating
relief after applying a cold compress
1.15. Ans: 1 The nursing assistant is able to
assist the client with hygiene issues and knows
the principles of safety and comfort for this
procedure. Monitoring the client, teaching
techniques, and evaluating outcomes are
nursing responsibilities. Focus: Delegation
16. The physician has ordered a placebo for a
client with chronic pain. You are a newly hired
nurse and you feel very uncomfortable
administering the medication. What is the rst
action that you should take? 1. Prepare the
medication and hand it to the physician 2. Check
the hospital policy regarding use of a placebo 3.
Follow a personal code of ethics and refuse to
participate 4. Contact the charge nurse for
advice
1.16. Ans: 4 Administering placebos is generally
considered unethical. Consult the charge nurse
as a resource person who can help you clarify
the situation and locate and review the hospital
policy. If the physician is insistent, he or she
could give the placebo. While following your
own ethical code is correct, you must ensure
that the client is not abandoned and that care
continues. Focus: Prioritization
17. For a cognitively impaired client who cannot
accurately report pain, what is the rst action
that you should take? 1. Closely assess for
nonverbal signs such as grimacing or rocking 2.
Obtain baseline behavioral indicators from
family members 3. Look at the MAR and chart to
note the time of the last dose of analgesic and
the client's response
1.17. Ans: 2 Complete information should be
obtained from the family during the initial
comprehensive history taking and assessment.
If this information is not obtained, the nursing
staff will have to rely on observation of
nonverbal behavior and careful documentation
to determine pain and relief patterns. Focus:
Prioritization
18. You received the shift report from the night
nurse. Prioritize the order in which you will
check on the following clients. 1. An adolescent
who is alert and oriented. He was admitted 2
days ago for treatment of meningitis. He
complains of continuous headache that is
partially relieved by medication. 2. An elderly
man who underwent total knee replacement
surgery 2 days ago. He is using the PCA pump
frequently with good relief and occasionally asks
for bolus doses. 3. A middle-aged woman who is
demanding and needy. She was admitted for
investigation of functional abdominal pain and is
scheduled for diagnostic testing this morning. 4.
A confused elderly woman who underwent
surgery 4 days ago for a hip fracture. She cries
out and struggles during any type of nursing
care, and it is difcult to assess her pain. 5. A
young man who was admitted with chest pain
secondary to a spontaneous pneumothorax. His
chest tube will be removed and his PCA pump
discontinued today. _____, _____, _____,
_____, _____
1.18. Ans: 5, 3, 1, 2, 4 All of the clients are in
relatively stable condition. The client with the
pneumothorax has priority, because chest tubes
can leak or become dislodged or blocked. Lung
sounds and respiratory effort should be
evaluated. The woman who is going for
diagnostic testing should be assessed and
medicated before she leaves for the procedure.
In a client with meningitis, a headache is not an
unexpected complaint, but neurologic status and
pain should be assessed. The report of
postoperative pain is expected, but this client is
getting reasonable relief most of the time.
Caring for and assessing the confused client is
likely to be very time consuming; leaving her to
the last prevents delaying care for all the others.
Focus: Prioritization
19. On the rst day after surgery, a client
receiving an analgesic via PCA pump reports
that the pain control is inadequate. What is the
rst action you should take? 1. Deliver the bolus
dose per standing order 2. Contact the physician
to increase the dose 3. Try nonpharmacologic
comfort measures 4. Assess the pain for
location, quality, and intensity
1.19. Ans: 4 Assess the pain for changes in
location, quality, and intensity, as well as
changes in response to medication. This
assessment will guide the next steps. Focus:
Prioritization
20. Which nonpharmacologic measure is
particularly useful for a client with acute
pancreatitis? 1. Diversional therapy, such as
playing cards or board games 2. Massage of the
back and neck with warmed lotion 3. Placement
in a side-lying position with knees to chest and
pillow against the abdomen 4. Transcutaneous
electrical nerve stimulation
1.20. Ans: 3 The side-lying, knee-chest position
opens the retroperitoneal space and provides
relief. The pillow supplies a splinting action.
Diversional therapy is not the best choice for
acute pain, especially if the activity requires
concentration. TENS is more appropriate for
chronic muscular pain. The additional
stimulation of massage may be distressing for
this client. Focus: Prioritization
21. What is the best way to schedule medication
for a client with constant pain? 1. Prn at the
client's request 2. Before painful procedures 3.
IV bolus after pain assessment 4. Around the
clock
1.21. Ans: 4 If the pain is constant, the best
schedule is around the clock, to provide steady
analgesia and pain control. The other options
may actually require higher dosages to achieve
control. Focus: Prioritization
22. Which of these client(s) would be
appropriate to assign to an LPN/LVN who will
function under the supervision of an RN or team
leader? (Select all that apply.) 1. A client who
needs preoperative teaching for the use of a
PCA pump 2. A client with a leg cast who needs
neurologic and circulatory checks and prn
hydrocodone 3. A client who underwent a toe
amputation and has diabetic neuropathic pain 4.
A client with terminal cancer and severe pain
who is refusing medication 5. A client who
complains of abdominal pain after being kicked,
punched, and beaten 6. A client with arthritis
who needs scheduled pain medications and
heat applications
1.22. Ans: 2, 3, 6 The clients with the cast, toe
amputation, and arthritis are in stable condition
and need ongoing assessment and pain
management that are within the scope of
practice of an LPN/LVN under the supervision of
an RN. The RN should take responsibility for
preoperative teaching, and the terminal cancer
client needs a comprehensive assessment to
determine the reason for refusal of medication.
The trauma client needs serial assessments to
detect occult trauma. Focus: Assignment
23. You are caring for a client who had
abdominal surgery yesterday. The client is
restless and anxious and tells you that the pain
is getting worse despite the pain medication.
Physical assessment ndings include the
following: temperature, 100.3 F (38 C); pulse
rate, 110 beats/min; respiratory rate, 24
breaths/min; and blood pressure, 140/90 mm
Hg. The abdomen is rigid and tender to the
touch. You decide to notify the client's provider.
Place the following report information in the
correct order according to the SBAR (situation,
background, assessment, recommendations)
format. 1. He is restless and anxious:
temperature is 100.3 F (38 C); pulse is 110
beats/min; respiratory rate is 24 breaths/min;
blood pressure is 140/90 mm Hg. Abdomen is
rigid and tender to touch with hypoactive bowel
sounds. 2. He had abdominal surgery
yesterday. He is on PCA morphine, but he says
the pain is getting progressively worse. 3. I
1.23. Ans: 5, 2, 1, 3, 4 Using the SBAR format,
the nurse rst identies himself or herself, gives
the client's name, and describes the current
situation. Next, relevant background information,
such as the client's diagnosis, medications, and
laboratory data, is stated. The assessment
includes both client assessment data that are of
concern and the nurse's analysis of the
situation. Finally, the nurse makes a
recommendation indicating what action he or
she thinks is needed. Focus: Prioritization
have tried to make him comfortable and he is
willing to wait until the next scheduled dose of
pain medication, but I think his pain warrants
evaluation. 4. Would you like to give me an
order for any laboratory tests or additional
therapies at this time? 5. Dr. S, this is Nurse J.
I'm calling about Mr. D, who is complaining of
severe abdominal pain. _____, _____, _____,
_____, ____
24. Which client(s) is appropriate to assign to a
newly graduated RN who has recently
completed orientation? (Select all that apply.) 1.
An anxious client with chronic pain who
frequently uses the call button 2. A client on the
second postoperative day who needs pain
medication before dressing changes 3. A client
with human immunodeciency virus (HIV)
infection who reports headache and abdominal
and pleuritic chest pain 4. A client with chronic
pain who is to be discharged with a new
surgically implanted catheter 5. A client who is
complaining of pain at the site of a peripheral IV
line 6. A client with a kidney stone who needs
frequent prn pain medication
1.24. Ans: 2, 5, 6 The client who is second day
postoperative, the client who has pain at the IV
site, and the client with the kidney stone have
predictable needs and require routine care that
a new nurse can manage. The anxious client
with chronic pain needs an in-depth assessment
of the psychological and emotional components
of pain and expert intervention. The client with
HIV infection has complex complaints that
require expert assessment skills. The client
pending discharge will need special and detailed
instructions. Focus: Assignment
24. Which client(s) is appropriate to assign to a
newly graduated RN who has recently
completed orientation? (Select all that apply.) 1.
An anxious client with chronic pain who
frequently uses the call button 2. A client on the
second postoperative day who needs pain
medication before dressing changes 3. A client
with human immunodeciency virus (HIV)
infection who reports headache and abdominal
and pleuritic chest pain 4. A client with chronic
pain who is to be discharged with a new
surgically implanted catheter 5. A client who is
complaining of pain at the site of a peripheral IV
line 6. A client with a kidney stone who needs
frequent prn pain medication
1.25. Ans: 3 Directly ask the client about the
pain and perform a complete pain assessment.
This information will determine which action to
take next. Focus: Prioritization
26. Pain disorder and depression have been
diagnosed in a client. He reports chronic low
back pain and complains, None of these
doctors has done anything to help. Which client
statement concerns you the most? 1. I twisted
my back last night, and now the pain is a lot
worse. 2. I'm so sick of this pain. I think I'm
going to nd a way to end it. 3. Occasionally I
buy pain killers from a guy in my neighborhood.
4. I'm going to sue you and the doctor; you
aren't doing anything for me.
1.26. Ans: 2 This statement is a veiled suicide
threat, and clients with pain disorder and
depression have a high risk for suicide. New
injuries must be evaluated, but this type of
complaint is not uncommon for clients with pain
disorder. Risk for substance abuse is very high
and should eventually be addressed. He can
threaten to sue, but current circumstances do
not support his case. Focus: Prioritization
27. A client has severe pain and bladder
distention related to urinary retention and
possible obstruction. An experienced nursing
assistant states that she received training in
Foley catheter insertion at a previous job. What
task can be delegated to this nursing assistant?
1. Assess the bladder distention and the pain
associated with urinary retention 2. Insert the
Foley catheter, once you ascertain that she
knows sterile technique 3. Evaluate the relief of
pain and bladder distention after the catheter is
inserted 4. Measure the urine output after the
catheter is inserted and obtain a urine specimen
1.27. Ans: 4 Measuring output and obtaining a
specimen are within the scope of practice of the
nursing assistant. Insertion of the Foley catheter
in this client should be done by the RN, because
clients with obstruction and retention are usually
very difcult to catheterize, and the nurse must
evaluate the pain response during the
procedure. The assistant's knowledge of sterile
technique is not the issue for this particular
client. Focus: Delegation
28. You are caring for a young man with a
history of substance abuse who had exploratory
abdominal surgery 4 days ago for a knife
wound. There is an order to discontinue the
PCA-delivered morphine and to start oral pain
medication. The client begs, Please don't stop
the morphine. My pain is really a lot worse today
than it was yesterday. What is the best
response? 1. Let me stop the pump and we can
try oral pain medication to see if it relieves the
pain. 2. I realize that you are scared of the
pain, but we must try to wean you off morphine.
3. Show me where your pain is and describe
how it feels compared to yesterday. 4. Let me
take your vital signs, and then I will call the
doctor and explain your concerns.
1.28. Ans: 3 Assessing the pain is the priority in
this acute care setting, because there is a risk of
infection or hemorrhage. The other options
might be appropriate based on your assessment
ndings. Focus: Prioritization
29. You are caring for a young client with 1.29. Ans: 2 Talk to the client about insulin and
diabetes who has sustained injuries when she
tried to commit suicide by crashing her car. Her
blood glucose level is 650 mg/dL, but she
refuses insulin; however, she wants the pain
medication. What is the best action? 1. Notify
the charge nurse and obtain an order for a
transfer to intensive care 2. Explain that insulin
is a priority and inform the health care provider
3. Withhold the pain medication until she agrees
to accept the insulin 4. Give her the pain
medication and document the refusal of the
insulin
ketoacidosis. If she is already aware of the
dangers of an elevated blood glucose level, then
her refusal suggests ongoing suicidal intent and
the provider should be notied so that steps can
be taken to override her refusal (potentially a
court order). A blood glucose level of over 600
mg/dL is typically a criterion for transfer to
intensive care, but arranging for transfer is not
the priority. Withholding the pain medication is
unethical, and merely documenting refusal of
insulin is inappropriate because of possible
ongoing suicidal intent. Focus: Prioritization

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