Nursing Interventions & Clinical Skills 6th Edition by Anne Griffin Perry Potter Ostendorf Test Bank

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Nursing Interventions & Clinical Skills 6th Edition by Anne Griffin Perry Potter Ostendorf Test Bank

Description

Chapter 13: Pain Management
Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition

MULTIPLE CHOICE

1. The nurse teaches the patient progressive self-relaxation techniques. Which should the nurse implement first?
a. Direct the patient to envision sailing on a sailboat.
b. Instruct the patient to increase respiratory rate and depth.
c. Establish the patients ability to participate and cooperate.
d. Darken the patients room significantly and close the door.

ANS: C
The nurse begins by assessing the patients ability to participate and cooperate to tailor the teaching techniques and vocabulary to him or her. This increases the likelihood of the patient benefiting from the instruction. Envisioning pleasant things is part of teaching guided imagery but is not the initial step. After assessing the patient, the nurse provides a brief overview of the technique and sets a proper learning environment. Deep respirations are an indication of relaxation; however, instructing a patient to breathe in a certain way does not induce relaxation.

DIF: Cognitive Level: Comprehend REF: Page 326
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

2. The nurse massages the patient to promote relaxation. Which is a suitable intervention for the nurse to implement during the massage?
a. Use the friction technique over the spine.
b. Assess for pain, anxiety, and discomfort.
c. Instruct the patient to sit upright and forward.
d. Knead the patients scalp with warm lotion.

ANS: B
The nurses goal during a massage is to keep the patient comfortable and relaxed and induce a lingering sense of well-being and relaxation at the completion of the massage. If the patient is in pain, anxious, or uncomfortable, relaxation does not occur until the noxious stimuli are eliminated. The nurse asks the patient about pain and comfort during the massage and does not wait for the patient to offer such statements. The friction technique (i.e., strong, circular strokes enhancing perfusion at the skins surface) is contraindicated for bony prominences such as the spine because the regional skin is already thin and under tension by nature of its location over a bone. Sitting upright and forward can be contraindicated or uncomfortable for the patient. Occasionally the patients scalp is massaged with a few drops of oil on the fingertips; it is impossible to knead the scalp because the scalp is devoid of large, thick muscles.

DIF: Cognitive Level: Comprehend REF: Page 321
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

3. The patient awakens at 3:00 AM requesting pain medication, but the nurse does not administer additional pain medication. What justifies the nurses decision to withhold the medication?
a. The patient had a reaction to aspirin 5 years ago.
b. The nurse wants to help the patient avoid drug addiction.
c. The patient is asleep when the nurse returns with analgesia.
d. The patient wants pain medication every 3 3/4 hours exactly.

ANS: C
The nurse receives contradictory messages about the patients pain level because the patient is relaxed enough to fall asleep again. To avoid oversedation and complications, the nurse withholds the medication but assesses the patient for other indicators of pain before leaving the room. The nurse promptly administers pain medication if other indicators of pain are present or when the patient awakens. Frequently nurses feel a duty to protect patients from drug addiction and to withhold pain medication when they suspect that the patient exhibits addictive behavior or asks for too much pain medication. Experts, including The Joint Commission, agree that healthcare professionals should rely on the patients report of pain. The patient has the right to effective pain management, and the nurse is bound ethically to provide pain relief when the patient asks for it. If the patient asks for pain medication every 3 3/4 hours, he or she may be watching the clock. Many healthcare professionals describe this behavior as drug seeking, meaning that the patient is seeking pain medication for unrelated reasons; this description labels the patient unfairly. This behavior can also indicate inadequate pain relief or the onset of a new patient health problem. For these reasons this type of patient request for pain medication warrants further investigation. To manage this situation, the nurse remembers the patients right to pain relief and the nurses role as patient advocate.

DIF: Cognitive Level: Analyze REF: Page 317| Page 328-329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation

4. The patient has hypotension, receives as much opioid analgesia as the prescription allows, and continues to have difficulty sleeping at night because of pain. Which should the nurse implement to relieve pain and improve sleep?
a. Encourage controlled breathing.
b. Provide a glass of wine at bedtime.
c. Give a sedative 1 hour before sleep.
d. Increase fluids and reposition the patient.

ANS: A
The nurse encourages the patient with controlled breathing exercises that serve as a distraction to increase relaxation, decrease pain, and promote sleep. The nurse applies a nonpharmacological relaxation technique because the patient has hypotension and additional analgesia is likely to lower the blood pressure further, potentially leading to serious complications, including loss of consciousness, decreased perfusion to vital organs, and cardiopulmonary arrest. Alcohol is contraindicated for use with opioids; in addition, alcohol consumption is likely to lower the blood pressure by vasodilation. The nurse avoids administering a sedative because hypotension is an adverse effect of most sedatives and sedatives will aggravate the patients hypotension. The nurse increases fluid if the patient has a fluid volume deficiency; however, restoring fluid balance is unlikely to promote relaxation to relieve pain and improve sleep. Until the patients hypotension is resolved, the nurse repositions him or her in the supine position or with the head slightly elevated to prevent increasing venous return from the head to the heart.

DIF: Cognitive Level: Analyze REF: Page 330
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

5. The nurse wants to use massage to promote relaxation. In which patient diagnosis would massage be potentially contraindicated?
a. Spinal cord injury
b. Hypertension
c. Acute asthma
d. Crohns disease

ANS: A
Massage may be contraindicated after spinal cord injuries or surgery to head and neck because of risk of further injury. Patients with hypertension, acute asthma, and Crohns disease potentially benefit from a massage as relaxation therapy.

DIF: Cognitive Level: Comprehend REF: Page 324
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment

6. The patient has metastatic bone pain from cancer with nausea and vomiting after receiving periodic opioid analgesia intravenously. Which can the nurse implement to manage the patients pain effectively without nausea and vomiting?
a. Dispense the opioid 30 minutes after providing food.
b. Combine the opioid with an antiemetic or antihistamine.
c. Collaborate with the healthcare provider for around-the-clock analgesia.
d. Replace the analgesic with a nonsteroidal anti-inflammatory agent.

ANS: C
Metastatic bone pain can be very difficult to control for a patient with cancer. The nurse collaborates with the provider to convert intravenous (IV) opioid administration to around-the-clock (ATC) dosing because ATC administration maximizes the pain relief and minimizes most side effects and drug toxicity. Administering opioids with food is an effective technique to avoid nausea and vomiting but usually only when the opioid is given by mouth. Although administering an antiemetic and/or an antihistamine with an opioid analgesic is a reasonable method of managing the patients nausea and vomiting, the periodic schedule is not as effective as ATC dosing. Nonsteroidal antiinflammatory agents may be used in combination with opioids for bone pain, but they do not replace the opioids.

DIF: Cognitive Level: Apply REF: Page 328| Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation

7. The patient receives opioid analgesia with naproxen (Naprosyn) after a total abdominal hysterectomy. Which patient datum is the nurses priority?
a. The patient has not had a bowel movement since surgery.
b. The patient declines a massage after analgesic administration.
c. Respiratory rate drops from 22 to 16 breaths/min.
d. The patient receives famotidine (Pepcid) for esophageal reflux.

ANS: D
A patient history of esophageal reflux is usually a contraindication for nonsteroidal antiinflammatory drug (NSAID) administration because of the increased risk of bleeding from prostaglandin inhibition. Constipation is a complication of surgery and opioid analgesia, but the nurse manages patient constipation by increasing patient ambulation and intake of fiber, fluid, and stool softeners. Declining a massage after receiving pain medication potentially indicates that the patient is satisfied with her comfort and relaxation status. Respirations at 16 breaths/min are within normal limits.

DIF: Cognitive Level: Analyze REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment

8. The nurse prepares an oral opioid analgesic for the patient who has dementia and pain. After checking the patients medication administration record (MAR) for the last administration time and the patients response to pain medication, the nurse chooses the correct analgesic and compares the patients picture and wristband to the medical record. Which is the most important intervention for the nurse to implement before administering pain medication to the patient?
a. Fill the pitcher with water.
b. Record the administration time.
c. Check the medication dose.
d. Help the patient to sit upright.

ANS: C
The most important intervention is to check the MAR and verify the correct dose before administration to prevent adverse effects and toxicity. This is important from a safety standpoint and follows the rights of medication preparation and administration. Filling the water pitcher can be delegated to nursing assistive personnel (NAP). Assisting the patient to a particular position may be required, but it is not the most important intervention in medication administration. Administering the correct dose is much more important. The nurse should be focused on safety during the preparation and administration of medication. Medication documentation occurs after the medication is administered.

DIF: Cognitive Level: Analyze REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

9. The nurse decides that collaboration with the healthcare provider is needed to review and possibly adjust the dose of analgesic for an 87-year-old patient. What is the rationale for this request?
a. Older adults have higher risks of injury with intramuscular (IM) injections.
b. Analgesics arent necessary for older adults because of decreased pain sensation.
c. Impaired cognition impairs reporting of pain by older patients.
d. Liver and kidney metabolism is usually slower in older adults.

ANS: D
As the adult ages, hepatic and renal clearance of medication usually decreases or slows, so medication has a longer duration of action, and doses exert a stronger effect than in younger people. The nurse helps to maintain patient safety and prevent injury by collaborating to adjust the dose of the analgesic. Risk of injury from an IM injection refers to the route of administration and is not dependent on the dose. Nothing in the question indicates that an IM injection is the mode of administration. The nurse uses the patients self-report of pain felt to help determine the need for pain relief; reporting pain refers to patient assessment. This option does not address the reason for adjusting the dosage.

DIF: Cognitive Level: Apply REF: Page 331
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

10. The patient who receives morphine sulfate intravenously by patient-controlled analgesia (PCA) tells the nurse that the pain level is 8 on a scale of 0 to 10. Which is the best intervention for the nurse?
a. Check the volume of morphine in the PCA syringe.
b. Check the frequency of patient-controlled dosing.
c. Collaborate with the provider to increase basal rate.
d. Instruct the family to activate the patient-controlled dose.

ANS: B
The PCA dose includes a basal rate to establish and maintain a therapeutic morphine serum level and a supplemental dose of morphine, the patient-controlled dose, for patient pain management. The nurse checks the frequency of patient self-dosing to gather additional information for a nursing assessment. If the patient is not supplementing the basal dose, the nurse instructs the patient to use the patient-controlled dose by directing the patient to depress the PCA button for pain control. The nurse allows 30 minutes to 1 hour to evaluate the plan. If the patient is using the PCA properly, the patient may benefit from an increased basal rate. If the patient is depressing the PCA button, the syringe of morphine may be empty; however, the PCA has an alarm to indicate low volume, and the nurse monitors the volume for narcotic control and intake and output (I&O), so it is unlikely that an empty syringe will be the problem. Collaborating with the provider to increase the PCA dose is premature because the nurse has not completed an assessment or implemented nursing interventions that potentially resolve the patients pain. The nurse avoids instructing the family to assist the patient because PCA is for patient use only, and families are unauthorized users of the patients PCA.

DIF: Cognitive Level: Analyze REF: Page 336
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation

11. The nurse cares for several postoperative patients using patient-controlled analgesia (PCA) pain management with a combination of an opioid and a local anesthetic agent on the first postoperative day. Which patient should the nurse assess first?
a. A patient after a bowel resection for recurrent colon cancer
b. A patient after an internal fixation of an ankle fracture
c. A first-time hospitalized patient after amputation of a leg
d. A patient with emphysema who had a lung tumor resection

ANS: C
The nurse assesses the patient with the amputation first. Since this is the patients first hospitalization, it is unknown how he or she will react to the pain medications, and they can cause respiratory depression. The patient with chronic obstructive pulmonary disease (COPD) is probably the second patient the nurse assesses because the disease is pulmonary. If the patient hypoventilates because the pain is too great, he or she is likely to retain additional carbon dioxide, inadequately oxygenate, and potentially have respiratory acidosis and respiratory failure. The other patients would be assessed as soon as possible.

DIF: Cognitive Level: Analyze REF: Page 332
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

12. The nurse assesses the patient who is 2 days postoperative to determine the need for continuing patient-controlled analgesia (PCA). Which information should the nurse use to decide that the patient is ready for oral administration of analgesia?
a. Patient is hypoventilating.
b. Pain level ranges from 2 to 4.
c. Sedation level is consistent.
d. BP is 168/96, HR 110, RR 26.

ANS: B
The nurse uses the patients pain level ranging from 2 to 4 to help determine that oral analgesia is suitable for him or her because the patients pain level is consistently below the mid-range on the pain scale. PCA is more suitable for moderate-to-severe pain, and oral analgesia is more suitable for low-to-moderate pain. Hypoventilation is an adverse effect of opioid analgesia, regardless of the administration method. Hypoventilation indicates that the patient potentially receives an excessive dose of opioid or that the dose remains inadequate and the patient is hypoventilating to prevent pain. A consistent sedation level is vague and provides little information about patient status. It can indicate a serious neurological impairment or excessive dosing and warrants further investigation. An elevated blood pressure, heart rate, and respiratory rate are nonverbal indicators of pain and indicate inadequate pain relief. However, these readings alone give no indication of the best route for administration of analgesia.

DIF: Cognitive Level: Analyze REF: Page 328
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation

13. The patient who receives patient-controlled analgesia (PCA) with an opioid analgesic reports that the pain level is 9 on a scale of 0 to 10. Which does the nurse implement to increase patient pain control?
a. Elevates the head of the bed (HOB) to 30 degrees
b. Increases the interval between demand doses
c. Increases the demand and the basal doses
d. Checks patient manipulation of the PCA button

ANS: D
The nurse checks to ensure that the patient understands and executes depression of the PCA button for on-demand doses. If the patient does not operate the button or does so ineffectively, he or she receives inadequate pain control. The nurse can elevate the HOB if the patient is oversedated and difficult to arouse unless it is contraindicated. By elevating the HOB, the nurse repositions and enables the patient to receive more environmental stimulation. The patient receives less medication when the time between demand doses is increased. The nurse avoids increasing the basal rate and demand dose simultaneously to prevent oversedation because increasing each rate of administration increases the total potential dose twice.

DIF: Cognitive Level: Application REF: Page 336
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation

14. The nurse receives the patient in the postanesthesia recovery unit and assesses the epidural analgesic infusion. Which is the nurses priority?
a. The filter needle is attached to the catheter tubing.
b. The distal end of the tubing is attached to the catheter.
c. The infusion contains an opioid and a local anesthetic.
d. The pump settings match the provider prescription.

ANS: C
Combining an opioid with a local anesthetic agent increases the patients risk of complications from epidural analgesia because adding another agent exposes the patient to the risks of both medications, risks from drug-drug interactions, and risks of epidural analgesia. The filter needle is used to remove microscopic debris as the medication is withdrawn from the medication vial and is removed before injecting the medication into the infusion fluid. A filter needle piggybacked into the epidural catheter is likely to increase the pressure necessary to pump the infusion through the catheter and activate the high-pressure alarm on the infusion pump. The nurse should replace the filter needle with a standard needle or needleless adapter. Attaching the distal end of the tubing to the epidural catheter is correct. Matching the pump settings to the provider prescription is expected nursing behavior.

DIF: Cognitive Level: Analyze REF: Page 328| Page 337
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

15. A patient is receiving care for a soft tissue sports injury. Which explanation by the nurse explains part of the treatment using the acronym PRICE?
a. Ill be alternating ice and heat to the injured area.
b. Youll be exercising with ice packs for a while.
c. Rest is indicated before and after cold treatments.
d. The cold therapy decreases venous congestion.

ANS: D
PRICE means protect from further injury, rest, ice, compression, and elevation, the standard treatment for a sports injury. The treatment decreases venous congestion as follows: rest decreases the gravitational pull on fluid to the extremity; ice vasoconstricts to limit edema, bleeding, and inflammation; compression prevents venous pooling; and elevation increases the gravitational pull on fluid from the affected region. Applying heat to an injury is usually contraindicated because it increases blood flow to the affected tissue. Exercise after a sports injury is applicable in selected cases and follows RICE therapy. The nurse usually recommends rest with a sports injury, but this is not the intended meaning of RICE.

DIF: Cognitive Level: Comprehension REF: Page 350
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment

16. The patient complains of a slight burning-like pain and numbness on the skin under a cold compress. Which action should the nurse take immediately?
a. Reassure the patient that some numbness is expected.
b. Assess the entire patient before continuing the treatment.
c. Remove the compress and assess the affected area.
d. Provide a warm blanket for the patients treatment.

ANS: C
Although sensation in the affected region changes during cold therapy, the nurse should first remove the compress and assess the area in response to the patient complaint. The patient will first sensation feel cold, followed by analgesia, burning skin pain, and numbness. Tingling is often associated with numbness as an indication of nerve impairment; thus the nurse assesses the patient before continuing therapy. The patients skin potentially benefits from passive rewarming and another nursing assessment to rule out tissue damage. Numbness in the affected region is associated with an increased risk of adverse effects from cold therapy. The nurse wants the patient to feel the cold and analgesic phases of cold therapy sensations. He or she assesses the tissue before discontinuing the cold therapy. Providing a blanket is a reasonable intervention as cold therapy begins to prevent shivering. However, although shivering consumes massive amounts of oxygen, the blanket is unlikely to affect the sensation of tissue treated with cold therapy.

DIF: Cognitive Level: Application REF: Page 350| Page 353
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

17. The nurse teaches the patient in ambulatory care to apply ice packs to an injured knee. What instructions should the nurse include in patient teaching?
a. Leave the ice on for no more than 5 minutes.
b. Remove the ice pack when the ice melts completely.
c. A cold pack has the potential to cause tissue damage.
d. Apply ice for an hour and then apply a heating pad.

ANS: C
The nurse should explain that prolonged application of ice can lead to tissue damage from prolonged vasoconstriction. The patient should be instructed to apply the ice for 10 to 20 minutes, then remove the ice for 30 minutes and check affected tissue before repeating the cycle to prevent tissue damage. Applying ice for 5-minute increments is subtherapeutic treatment. The nurse avoids teaching the patient to leave the ice in place until it melts because it is likely to result in ice application exceeding 20 minutes and increase the risk for tissue damage. Application of ice for 1 hour exceeds the 20-minute recommendation to prevent tissue damage.

DIF: Cognitive Level: Application REF: Page 351
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation

18. The school nurse provides first aid to the 10-year-old student with a new uncomplicated arm fracture. The nurse wants to provide nonpharmacological pain relief and minimize regional edema. Which first-aid treatment does the nurse provide for the patient?
a. A cold compress
b. A covered ice bag
c. An aquathermia pad
d. A moist heat compress

ANS: B
The nurse applies an ice bag with a cover between it and the students arm to reduce pain, swelling, and bleeding because cold therapy provides a regional anesthetic effect and vasoconstricts to limit regional blood flow. The nurse protects the students arm from thermal injury by wrapping the ice bag before the application. A cold compress is inadequate to provide regional vasoconstriction for a fractured arm. Heat application from an aquathermia pad or a moist compress is contraindicated for the fracture because both therapies increase blood flow and promote vasodilation. The fluid pressure in the area can increase from the heat to increase patient pain, bleeding, and edema.

DIF: Cognitive Level: Application REF: Page 350
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation

19. The nurse plans care for four patients receiving heat therapy. Which patient admission diagnosis presents the highest risk of injury to an extremity?
a. Osteoarthritis
b. Nephrolithiasis
c. Chronic bronchitis
d. Peripheral neuropathy

ANS: D
The patient admitted for a peripheral neuropathy has the highest risk for a heat therapy injury because he or she has impaired sensation to the extremities, meaning that the patient has difficulty sensing pain, heat, and pressure. This patient is more likely to incur tissue damage from heat therapy because he or she has impaired ability to sense excessive heat. The patient with osteoarthritis can have a slightly higher risk of thermal injury from heat therapy if patient mobility is impaired because a self-protective mechanism is withdrawal from noxious sensations such as excessive heat. Patients with nephrolithiasis, kidney stones, and chronic bronchitis can be suitable candidates for heat therapy because these diagnoses are unrelated to peripheral perfusion, sensation, or movement.

DIF: Cognitive Level: Analyze REF: Page 348
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment

20. The nursing assistive personnel (NAP) reports that the patient is dizzy during a warm sitz bath. Which action should the nurse take before moving the patient?
a. Check the patients pulse rate.
b. Dry off the patient completely.
c. Ask the patient if he or she is able to ambulate.
d. State that dizziness is common.

ANS: A
The nurse should assess the patients pulse rate to determine if the patient is stable enough to either continue the bath or ambulate back to bed with assistance. Unless a sphygmomanometer is readily available, taking the pulse is a good clinical indicator to evaluate hypotension indirectly because when the blood pressure falls, the heart rate increases to maintain the cardiac output. The patient should remain in place until the nurse assesses him unless he has a cardiovascular or chronic pulmonary condition and is shivering. If one of these conditions is present, the nurse and the NAP should dry off the patient, provide warm clothing, and return him to bed. Dizziness is a common response to a warm bath for patients who are older or who have cardiovascular, neurovascular, or chronic pulmonary conditions, but the nurse needs to assess the patient before deciding what is happening.

DIF: Cognitive Level: Apply REF: Page 348
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

21. The nurse admits a patient with left hand and wrist cellulitis. Which action does the nurse take when applying dry heat to the area using an aquathermia pad?
a. Keeps the fluid chamber in the device empty
b. Covers the pad with a towel or pillowcase
c. Positions the patient directly on the pad
d. Sets the aquathermia temperature at 36.6 C (98 F)

ANS: B
To implement dry heat with an aquathermia pad, the nurse covers the pad with a layer of insulation to help prevent skin exposure to excessive heat that potentially leads to maceration. The nurse sustains the fluid in the aquathermia pad reservoir because the heat that it provides radiates from warm fluid circulating through the pad. The nurse avoids positioning a patient directly on an aquathermia pad for heat therapy because it increases the risk of burns and tissue maceration. An aquathermia pad is usually set at 40.5 C (105 F).

DIF: Cognitive Level: Apply REF: Page 346
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation

22. In the postanesthesia care unit the nurse applies an ice bag to the patients leg at the surgical site. Which therapeutic effect does the nurse expect from this treatment?
a. Decreased pain and diaphoresis
b. Decreased bleeding and vasoconstriction
c. Vasodilation and decreased blood flow
d. Increased oxygenation and increased inflammation

ANS: B
The nurse applies cold therapy to the patients surgical site for regional vasoconstriction, which also decreases bleeding. Diaphoresis commonly occurs with dry heat therapy, but decreased pain can occur with cold or heat therapy, depending on the type of injury. Cold therapy causes vasoconstriction, not vasodilation, and blood flow is decreased as a result of vasoconstriction.

DIF: Cognitive Level: Comprehend REF: Page 350
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

23. The patient received treatment for a sprained ankle and is receiving home care instructions regarding cold therapy. Which instructions should the nurse include?
a. Place the gel pack on the ankle for 30 minutes every 4 hours for the first 48 hours after the injury.
b. Wrap the ankle with a lightweight cloth before applying the ice bag to it.
c. Wrap the elastic bandage firmly before applying the ice to the ankle.
d. Immerse the foot in a pan of ice water every 4 hours for as long as the patient can wiggle his toes.

ANS: B
The patient needs to prevent direct exposure of the skin to the ice bag. The gel pack must be wrapped before being put against the ankle. The elastic bandage can interfere with circulation if wrapped too tightly, and the wrap itself can prevent the cold from being effective. Immersion would require the patient to place his foot in a dependent position, which can increase swelling.

DIF: Cognitive Level: Apply REF: Page 351
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

MULTIPLE RESPONSE

1. The nurse assesses the patient and realizes that patient pain is interfering with postoperative therapies. Which does the nurse determine before using medication and relaxation techniques simultaneously to reduce patient pain? (Select all that apply.)
a. The patient has used guided imagery in the past successfully.
b. Nonpharmacological relaxation methods appeal to the patient.
c. The patient moves in the bed and disrupts the nurse incessantly.
d. The provider plans to discharge the patient to home in 2 days.
e. The patient understands written information on relaxation techniques.
f. The patient cannot receive additional analgesia for unresolved pain.

ANS: A, B, C, F
An integrated approach using pharmacological and nonpharmacological therapies is the most effective method of pain management. Patients who potentially benefit the most from integrated therapies share certain qualities, including successful use of nonpharmacological therapies in the past. A patient who uses relaxation techniques such as guided imagery and massage is more likely to find these techniques appealing as long as the patient achieves success with the technique. Another patient likely to benefit from an integrated approach is the patient with anxiety or fear; excessive movements and disruptions are indications of a problem, including anxiety or fear, which potentially the patient cannot identify. A patient who cannot receive additional pain medication despite continuing pain is likely to benefit from integrated therapy as well. The discharge date is unrelated to assessing the patient before relaxation and guided imagery. The nurse can explain and demonstrate relaxation therapies and guided imagery without the patient reading.

DIF: Cognitive Level: Apply REF: Page 319
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

2. The nurse caring for a female patient 1 day after a thoracotomy assesses that the patient is in pain, but the patient states that she has no pain. Which does the nurse use to confirm the patients pain?(Select all that apply.)
a. Facial grimacing during linen changes
b. Eats a full liquid diet without assistance
c. Uses the incentive spirometer every hour
d. Patients culture forbids complaints of pain
e. Has received nothing for pain since surgery
f. Heart rate 110, blood pressure 169/90

ANS: A, D, E, F
To confirm the pain assessment for a patient who states that she has no pain, the nurse looks for information consistent with a patient in pain. The patients verbal message and nonverbal cues are contradictory because facial grimacing is a hallmark sign of pain and discomfort, especially when the patient moves. A potential explanation for the inconsistent verbal and nonverbal messages is that the patients culture forbids admitting to pain, necessitating the use of other pain indicators. A thoracotomy usually has a painful postoperative course because the surgical incision is stretched every time the patient breathes; thus a patient who receives no analgesia on the first postoperative day is very unusual. Tachycardia and hypertension are good clinical indicators of pain when the patient expresses contradictory messages about pain. The blood pressure increases because the patient becomes tense and contracts muscle, increasing the force necessary to drive blood through the vasculature. The heart rate increases from the stress response to pain and the resultant surge of epinephrine from the sympathetic nervous system. Eating and breathing deeply are inconsistent with a patient in pain.

DIF: Cognitive Level: Analyze REF: Page 317-318
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment

3. The nurse assesses a patient who has an epidural catheter for patient-controlled analgesia (PCA) on the second postoperative day. Which patient data does the nurse group together to establish the nurses priority? (Select all that belong to the group.)
a. Temperature 38.1 C (100.6 F)
b. Patient ready for oral analgesia
c. Low tension on epidural catheter
d. Respiratory rate 14, sedation level 1
e. Epidural drainage looks like medication
f. Hemoglobin 15 mg/dL, leukocytes 14,500

ANS: A, E, F
According to the nursing process, the nurse groups interrelated data together to draw a conclusion. This patient is febrile with leukocytosis and clear epidural drainage, clinical indicators of a potential infection. Because fluid is leaking from the insertion site, microorganisms have a potential portal of entry, even though the fluid is of unknown origin. The nurse collaborates with the provider to discontinue the epidural catheter, initiate therapy to eradicate potential infection, and provide adequate pain management by another route. If the fluid is cerebrospinal fluid (CSF), the patient is at risk for a devastating neurological infection and sepsis. Patient readiness for oral analgesia is not as important to patient health and well-being as dealing with the potential infection. Low tension on the catheter, a respiratory rate within normal limits, and a low sedation level are desirable patient data. They are not disregarded by the nurse in formulating nursing care but are less important than a potential infection. The nurse plans nursing care to enhance positive patient assessments to promote health and well-being.

DIF: Cognitive Level: Analyze REF: Page 339
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Diagnosis

4. The nurse prepares patient-controlled analgesia (PCA) for a postoperative patient in the postanesthesia recovery unit (PACU). To rule out contraindications to therapy, which should the nurse assess before the patient receives PCA?(Select all that apply.)
a. Consider patient cognitive level.
b. Evaluate patient communication.
c. Confirm two separate intravenous (IV) infusions.
d. Determine patient physical ability.
e. Assess for history of constipation.
f. Verify patient medication allergies.

ANS: A, B, D, F
The nurse assesses the patients cognitive level to verify suitability of PCA for pain management. If the patient cannot understand instructions, PCA will have little value to the patient in managing pain. The nurse evaluates communication to ensure patient ability to relate pain levels effectively; if the patient does not speak English or is cognitively impaired, the nurse establishes a method of nonverbal communication to determine pain level and effectiveness of therapy. The nurse ensures the patients physical ability to depress the PCA button. He or she checks patient allergies to medication before initiating PCA to prevent hypersensitivity reactions. One IV infusion is sufficient for PCA if the infusion is continuous or only infuses the PCA. If PCA is infused through the same tubing as intermittent infusions, the nurse risks bolus administration of the opioid and possibly the local anesthetic agent; this increases the risk of respiratory depression. Constipation does not contraindicate the use of PCA.

DIF: Cognitive Level: Apply REF: Page 332
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning

MATCHING

The nurse prepares to administer pain medication to a patient. Place the following nursing interventions in order, beginning with the initial action of the nurse to administer pain medication safely.
a. Compare routes on an equianalgesic chart.
b. Determine the patient response to analgesia.
c. Ask the patient to rate the pain a scale of 1 to 10.
d. Check the last analgesia administration time.

1. Step 1

2. Step 2

3. Step 3

4. Step 4

1. ANS: C DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: When changing to another route, the nurse refers to the opioid equianalgesic chart to ensure equal potency of two or more routes of the same medication. This helps to make sure that the patient receives the same-strength dose when the administration route changes.

2. ANS: D DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: After administering the analgesic, the nurse asks the patient to quantify the pain, to evaluate the effectiveness of the analgesic, and allows a suitable time interval after administration.

3. ANS: A DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: The process begins as the nurse asks the patient to quantify the pain to help assess the need for analgesia and establish baseline data.

4. ANS: B DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: To avoid the risk of adverse effects and administering pain medication before the interval specified on the prescription, the nurse checks the medication administration record (MAR) for the last administration time of the analgesic.

The nurse prepares to administer patient-controlled analgesia (PCA) to a patient. Rank the nursing interventions in sequential order.
a. Allow the patient to depress the PCA system button before infusion begins.
b. Prime the tubing with medication from the drug reservoir.
c. Instruct the patient that lockout time prevents overdose.
d. Insert the PCA tubing into the injection port nearest the patient.

5. Step 1

6. Step 2

7. Step 3

8. Step 4

5. ANS: B DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: The nurse initiates PCA administration by explaining the purpose and demonstrating the function of PCA to the patient and family to ensure patient understanding of PCA and to fulfill a patient right to information and informed consent.

6. ANS: C DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: Part of patient preparation for PCA is to provide an opportunity for the patient to try the PCA button before beginning the infusion.

7. ANS: A DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: The nurse properly programs the PCA infusion device according to agency policy and then primes the PCA tubing before inserting it into the intravenous (IV) port.

8. ANS: D DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: To avoid filling a long length of IV tubing with opioid medication, the nurse uses the port closest to the patient; the shorter the distance between the medication and the patient, the lower the amount of medication in the tubing, and the smaller the potential dose of accidental bolus administration.

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