Unit 3 NUR164 Questions With Complete Solutions
When the nurse assists a patient recovering from abdominal
surgery to walk, the nurse observes that the patient grimaces,
moves stiffly, and becomes pale. The nurse received in shift
report that the patient has consistently refused pain medication.
To help promote comfort, which additional data will the nurse
gather? Select all that apply.
a. Patient's understanding of or fear of taking prescribed
analgesics
b. Assessment of any current pain
c. Presence of anxiety or additional stressors
d. Assessment of the surgical incision for infection
e. What the patient has eaten to this point
f. Whether the patient is using the incentive spirometer
a, b, c, d. While it seems the patient's immediate problem is
unrelieved pain because the patient refuses to take pain
medication, through further assessment, the nurse can plan to
address fears of medication, teach about use of the pump,
determine if anxiety is interfering with pain, or an infection is
causing increased pain. While decreased oral intake may be a
response to pain, the patient's dietary intake will not uncover the
underlying reason for refusing medications. Use of the incentive
spirometer is not included in pain assessment; rather, it is an
intervention to prevent atelectasis
When developing the care plan for a patient with chronic pain,
the nurse plans interventions based on the knowledge that
,chronic pain not related to cancer or palliative/end-of-life care is
most effectively relieved through which method?
a. Providing the highest effective dose of an opioid on a PRN (as
needed) basis
b. Using nonopioid drugs conservatively
c. Applying multimodal nonpharmacologic and nonopioid
pharmacologic therapies
d. Administering a continuous intravenous infusion on a regular
basis
c. Nonpharmacologic and nonopioid pharmacologic therapies
(multimodal) are the preferred choices for chronic pain that is
unrelated to active cancer, palliative care, or end-of-life care. If
progression to opioids becomes necessary, the lowest effective
dose of an immediate-release opioid should be initiated first.
Ongoing assessment and careful monitoring should guide the
prescription of opioids for the management of chronic pain
(Dowell et al., 2016). A PRN (as needed) drug regimen has not
been proven effective for people experiencing chronic or acute
pain. When caring for a patient with acute pain, such as
postoperative pain, medication should be offered or requested
before pain becomes severe or unbearable. Once pain is
adequately treated, such as later in the postoperative course, a
PRN schedule may be effective.
When assessing pain in a child, the nurse needs to be aware of
what considerations?
a. Immature neurologic development results in reduced pain
sensation
b. Inadequate or inconsistent relief of pain is widespread
,c. Reliable assessment tools are currently unavailable
d. Narcotic analgesic use should be avoided
b. Health care personnel are placing awareness of pain relief in
children as a priority. The evidence supports the fact that
children do indeed feel pain, and reliable assessment tools are
available specifically for use with children. Opioid analgesics
may be safely used with children as long as they are carefully
monitored.
A pregnant woman has received an epidural analgesic prior to
delivery. Assessment for which outcome to the medication will
the nurse prioritize?
a. Pruritus
b. Urinary retention
c. Vomiting
d. Respiratory depression
d. An opioid drug given by way of an epidural catheter or a
displaced catheter may result in the occurrence of respiratory
depression. Pruritus, urinary retention, and vomiting may occur
but are not life threatening.
A nurse is assessing a patient receiving a continuous opioid
infusion. For which outcome of treatment would the nurse
immediately notify the primary care provider?
a. A respiratory rate of 11/min with normal depth
b. A sedation level of 4
c. Mild forgetfulness
d. Reported constipation
, b. Sedation levels predict respiratory depression. The sedation
scale uses: S = sleep, easy to arouse: no action necessary; 1 =
awake and alert; no action necessary; 2 = occasionally drowsy
but easy to arouse; requires no action; 3 = frequently drowsy and
drifts off to sleep during conversation; decrease the opioid dose;
and 4 = somnolent with minimal or no response to stimuli;
discontinue the opioid and consider use of naloxone. A
respiratory level of 11 with normal depth of breathing is usually
not a cause for alarm. Mild forgetfulness or confusion may
result from opioids; additional observation is necessary.
Constipation is not life threatening; it should be reported to the
health care provider but is not the priority.
A patient is receiving a multimodal medication regimen as part
of the treatment plan for neuropathic phantom limb pain. When
the patient reports a bloody bowel movement, which medication
prescription requires notification of the provider?
a. Acetaminophen
b. Nonsteroidal anti-inflammatory
c. Opioid medication
d. Antianxiety medication
b. The NSAIDs are contraindicated in patients with bleeding
disorders (their action may interfere with platelet function). The
nurse will hold the medication and collaborate with the provider
to adjust the patient's prescriptions.
A nurse on an adult surgical floor enters a patient room and
observes a family member pressing the button to administer a
dose of PCA via the infusion pump. What response by the nurse
When the nurse assists a patient recovering from abdominal
surgery to walk, the nurse observes that the patient grimaces,
moves stiffly, and becomes pale. The nurse received in shift
report that the patient has consistently refused pain medication.
To help promote comfort, which additional data will the nurse
gather? Select all that apply.
a. Patient's understanding of or fear of taking prescribed
analgesics
b. Assessment of any current pain
c. Presence of anxiety or additional stressors
d. Assessment of the surgical incision for infection
e. What the patient has eaten to this point
f. Whether the patient is using the incentive spirometer
a, b, c, d. While it seems the patient's immediate problem is
unrelieved pain because the patient refuses to take pain
medication, through further assessment, the nurse can plan to
address fears of medication, teach about use of the pump,
determine if anxiety is interfering with pain, or an infection is
causing increased pain. While decreased oral intake may be a
response to pain, the patient's dietary intake will not uncover the
underlying reason for refusing medications. Use of the incentive
spirometer is not included in pain assessment; rather, it is an
intervention to prevent atelectasis
When developing the care plan for a patient with chronic pain,
the nurse plans interventions based on the knowledge that
,chronic pain not related to cancer or palliative/end-of-life care is
most effectively relieved through which method?
a. Providing the highest effective dose of an opioid on a PRN (as
needed) basis
b. Using nonopioid drugs conservatively
c. Applying multimodal nonpharmacologic and nonopioid
pharmacologic therapies
d. Administering a continuous intravenous infusion on a regular
basis
c. Nonpharmacologic and nonopioid pharmacologic therapies
(multimodal) are the preferred choices for chronic pain that is
unrelated to active cancer, palliative care, or end-of-life care. If
progression to opioids becomes necessary, the lowest effective
dose of an immediate-release opioid should be initiated first.
Ongoing assessment and careful monitoring should guide the
prescription of opioids for the management of chronic pain
(Dowell et al., 2016). A PRN (as needed) drug regimen has not
been proven effective for people experiencing chronic or acute
pain. When caring for a patient with acute pain, such as
postoperative pain, medication should be offered or requested
before pain becomes severe or unbearable. Once pain is
adequately treated, such as later in the postoperative course, a
PRN schedule may be effective.
When assessing pain in a child, the nurse needs to be aware of
what considerations?
a. Immature neurologic development results in reduced pain
sensation
b. Inadequate or inconsistent relief of pain is widespread
,c. Reliable assessment tools are currently unavailable
d. Narcotic analgesic use should be avoided
b. Health care personnel are placing awareness of pain relief in
children as a priority. The evidence supports the fact that
children do indeed feel pain, and reliable assessment tools are
available specifically for use with children. Opioid analgesics
may be safely used with children as long as they are carefully
monitored.
A pregnant woman has received an epidural analgesic prior to
delivery. Assessment for which outcome to the medication will
the nurse prioritize?
a. Pruritus
b. Urinary retention
c. Vomiting
d. Respiratory depression
d. An opioid drug given by way of an epidural catheter or a
displaced catheter may result in the occurrence of respiratory
depression. Pruritus, urinary retention, and vomiting may occur
but are not life threatening.
A nurse is assessing a patient receiving a continuous opioid
infusion. For which outcome of treatment would the nurse
immediately notify the primary care provider?
a. A respiratory rate of 11/min with normal depth
b. A sedation level of 4
c. Mild forgetfulness
d. Reported constipation
, b. Sedation levels predict respiratory depression. The sedation
scale uses: S = sleep, easy to arouse: no action necessary; 1 =
awake and alert; no action necessary; 2 = occasionally drowsy
but easy to arouse; requires no action; 3 = frequently drowsy and
drifts off to sleep during conversation; decrease the opioid dose;
and 4 = somnolent with minimal or no response to stimuli;
discontinue the opioid and consider use of naloxone. A
respiratory level of 11 with normal depth of breathing is usually
not a cause for alarm. Mild forgetfulness or confusion may
result from opioids; additional observation is necessary.
Constipation is not life threatening; it should be reported to the
health care provider but is not the priority.
A patient is receiving a multimodal medication regimen as part
of the treatment plan for neuropathic phantom limb pain. When
the patient reports a bloody bowel movement, which medication
prescription requires notification of the provider?
a. Acetaminophen
b. Nonsteroidal anti-inflammatory
c. Opioid medication
d. Antianxiety medication
b. The NSAIDs are contraindicated in patients with bleeding
disorders (their action may interfere with platelet function). The
nurse will hold the medication and collaborate with the provider
to adjust the patient's prescriptions.
A nurse on an adult surgical floor enters a patient room and
observes a family member pressing the button to administer a
dose of PCA via the infusion pump. What response by the nurse
