NUR155 / NUR 155 Exam 4 Review | Latest 2026/2027 Update | Foundations of Nursing | Galen | Correct Questions & Accurate Solutions

NUR155 / NUR 155 Exam 4 Review | Latest 2026/2027 Update | Foundations of Nursing | Galen | Correct Questions & Accurate Solutions The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this infant? 1. FLACC scale 2. Wong-Baker FACES 3. Visual analog scale 4. Numeric rating scale 1. FLACC scale The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication? 1. Gastrointestinal (GI) distress 2. Shakiness 3. Tremors 4. Rash 1. Gastrointestinal (GI) distress Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid medication to a client? 1. Pain level as stated by client 2. Any nausea the client may be feeling 3. Respiratory rate 4. Color of skin 3. Respiratory rate The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need another dose of the medication? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours 2. 4 hours The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been vomiting all day. Which route should the nurse use to administer the medication? 1. Oral 2. Vaginal 3. Rectal 4. Intravenous 3. Rectal A client recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain? 1. Phantom limb pain 2. Acute pain 3. Chronic pain 4. Narcotic-induced pain 1. Phantom limb pain The nurse is providing discharge instructions to a client prescribed an opioid medication. What should the nurse suggest to decrease the risk of constipation with this medication? 1. Take an antihistamine three times per day. 2. Drink 6 to 8 glasses of water per day. 3. Assess respiratory rate before taking medication. 4. Assess heart rate before taking medication. 2. Drink 6 to 8 glasses of water per day. The nurse is caring for a client who is using morphine through patient-controlled analgesia (PCA). What medication should the nurse have readily available? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline 1. Naloxone hydrochloride (Narcan) The client is taking meperidine (Demerol) and experiencing pruritus. Which medication should the nurse expect the physician to order? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline 3. Diphenhydramine hydrochloride (Benadryl) The nurse is admitting a client to the emergency department with complaints of severe abdominal pain. What is the nurse's first action? 1. Administer IV pain medication as ordered. 2. Start an IV line of lactated Ringer's. 3. Assess pain using a scale of 1 to 10. 4. Place a Foley catheter to bedside drainage. 3. Assess pain using a scale of 1 to 10. A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain experienced but only some left shoulder pain. The nurse should explain that the client experienced which type of pain? 1. Phantom pain 2. Referred pain 3. Visceral pain 4. Chronic pain 2. Referred pain A client rates pain as being 7 on a scale from 0 to 10. What should the nurse document as this client's pain intensity? 1. Mild pain 2. Moderate pain 3. Severe pain 4. Physiological pain 3. Severe pain A client is experiencing pain after spraining an ankle. The nurse realizes that the client is most likely experiencing which type of pain? 1. Mild pain 2. Severe pain 3. Somatic pain 4. Visceral pain 3. Somatic pain The client scheduled to undergo minor surgery states, "The physician will not give me pain medication after surgery because my surgery is only minor." What is the best response by the nurse? 1. "You can experience pain after minor surgery, so you can have pain medication." 2. "You are correct. The physician will not order any pain medication." 3. "You are correct. I will need to teach you nonpharmacologic pain relief measures." 4. " You can only have about half the dose because your surgery is minor." 1. "You can experience pain after minor surgery, so you can have pain medication." The nurse is performing discharge teaching for a client taking an NSAID. The client states he has heard that taking an antacid with this medication will help decrease the incidence of upset stomach. What is the nurse's best response? 1. "Antacids reduce the absorption and therefore the effectiveness of the NSAID." 2. "Antacids help to reduce the incidence of gastric bleeding that could occur with the use of NSAIDs." 3. "Antacids should never be taken with an NSAID." 4. "Antacids help to reduce the incidence of pain." 1. "Antacids reduce the absorption and therefore the effectiveness of the NSAID." The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician? 1. Pulse rate: 80 2. Respiratory rate: 8 3. Blood pressure: 120/80 4. Pain rating of 4 on scale of 1 to 10 2. Respiratory rate: 8 A client states that a cramping pain started 2 hours ago and is not accompanied by any nausea or vomiting. Which type of pain is this client most likely experiencing? 1. Chronic pain 2. Phantom pain 3. Visceral pain 4. Acute pain 4. Acute pain The nurse is preparing to conduct a pain assessment. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. Duration 2. Location 3. Intensity 4. Etiology 5. Neurology 1. Duration 2. Location 3. Intensity 4. Etiology A client experiencing pain has been prescribed aspirin. The nurse realizes that this medication will affect which pain process? 1. Transduction 2. Transmission 3. Perception 4. Modulation 1. Transduction A client is complaining of having the same type of pain that he experienced prior to being diagnosed with cancer. The nurse realizes that which process will influence this client's perception of pain? 1. Transmission 2. Modulation 3. Perception 4. Transduction 3. Perception A client tells the nurse that an ice pack works well to reduce the intensity of back pain. The nurse realizes that the client is implementing 1. a placebo. 2. distraction. 3. guided imagery. 4. the gate control theory of pain. 4. the gate control theory of pain. A client recovering from hip surgery is reluctant to ambulate because of the amount of pain that occurred with walking prior to the surgery. What can the nurse do to help this client with pain control? 1. Provide pain medication before every ambulation session. 2. Address the client's fear of pain with walking. 3. Tell the client that the pain is now gone. 4. Explain that the client is confusing postoperative pain with the pain before the surgery. 2. Address the client's fear of pain with walking. The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client? Standard Text: Select all that apply. 1. Talk with the client about pain. 2. Provide privacy. 3. Present choices for dealing with pain. 4. Encourage distraction with music or television. 5. Allay fears and anxiety. 1. Talk with the client about pain. 2. Provide privacy. 3. Present choices for dealing with pain. 4. Encourage distraction with music or television. An older client who refuses medication for pain is irritable and unable to sleep. What should the nurse explain to the client to encourage the use of pain medication? Standard Text: Select all that apply. 1. There are high-dose medications that will eradicate the pain. 2. The lack of pain control is causing the inability to sleep. 3. The lack of pain control is causing irritability. 4. The risks of taking pain medication are low in the older population. 5. The lack of pain control will affect mobility and activity tolerance. 2. The lack of pain control is causing the inability to sleep. 3. The lack of pain control is causing irritability. 5. The lack of pain control will affect mobility and activity tolerance. A client with pain has had previous episodes of uncontrolled pain in the past and is worried about the current pain pattern. Which diagnosis would be appropriate for the nurse to include for this client? 1. Anxiety 2. Ineffective Coping 3. Deficient Knowledge 4. Hopelessness 1. Anxiety From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time? Standard Text: Select all that apply. 1. Anxiety 2. Hopelessness 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility A client experiencing chronic pain is not getting relief with pain medication. What should the nurse do to help this client? 1. Ask the physician to change the prescribed pain medication. 2. Reassess the pain and consider another pain relief measure. 3. Limit interaction with the client. 4. Stop using alternative pain relief measures, if not effective. 2. Reassess the pain and consider another pain relief measure. A client's pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time? 1. Provide NSAID medication as prescribed. 2. Coach the client with guided imagery. 3. Suggest the client read or watch television until the pain subsides. 4. Provide opioid analgesic as prescribed. 4. Provide opioid analgesic as prescribed. A client recovering from back surgery is refusing pain medication for fear of becoming addicted. What should the nurse say to the client? 1. "I understand." 2. "There are ways to treat addictions to pain medications." 3. "If the medication is taken to treat pain, you will not become addicted to it." 4. "All pain medication causes addiction. There is nothing that can be done to prevent it." 3. "If the medication is taken to treat pain, you will not become addicted to it." A client experiencing pain after surgery says "Something must be wrong" because the pain is so severe. What is the best response for the nurse to make to the client? 1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel." 2. "That could be so." 3. "Taking pain medication for many years has made the medication ineffective now." 4. "Are you sure the pain is as bad as you are saying it is?" 1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel." A client has been taking medication for back pain for several months, and has seen several different health care providers in efforts to receive pain medication. The nurse is concerned that the client is exhibiting 1. tolerance. 2. addiction. 3. physical dependence. 4. pseudoaddiction. 2. addiction. A client repeatedly asks the nurse "How much longer until I can get more pain medication?" Once the medication is provided, the client stops asking for it. The nurse identifies the client's behavior as being 1. addiction. 2. tolerance. 3. pseudoaddiction. 4. physical dependence 3. pseudoaddiction. A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare to administer what medications to the client? Standard Text: Select all that apply. 1. Nortriptyline 2. Amitriptyline 3. Tramadol 4. Meloxicam 5. Gabapentin 1. Nortriptyline 2. Amitriptyline 5. Gabapentin A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications should the nurse consider for the client at this time? Standard Text: Select all that apply. 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) 4. Hydrocodone (Vicodin) 5. Methadone (Dolophine) 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) After receiving medication for mild pain, the client states that the pain is getting worse. What should the nurse plan to do for this client? 1. Administer another dose of a nonopioid medication. 2. Administer an opioid for severe pain. 3. Administer an opioid for moderate pain. 4. Administer two doses of an opioid for moderate pain. 3. Administer an opioid for moderate pain. A client is prescribed a medication that is a blend of an opioid analgesic with an NSAID. The nurse realizes that this medication will have which effects on the client? Standard Text: Select all that apply. 1. Encourage the development of tolerance. 2. Encourage the development of addiction. 3. Maximize pain control while minimizing toxicity. 4. Maximize pain control while minimizing side effects. 5. Reduce the onset of pseudoaddiction. 3. Maximize pain control while minimizing toxicity. 4. Maximize pain control while minimizing side effects. A client is diagnosed with chronic low back pain syndrome. The nurse realizes that which analgesic delivery route might be beneficial for this client? 1. Topical 2. Rectal 3. Transmucosal 4. Transdermal 1. Topical A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control? 1. Body 2. Mind 3. Social interactions 4. Spirit 3. Social interactions The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What should the nurse include in these instructions? Standard Text: Select all that apply. 1. Massage 2. Acupressure 3. Self-hypnosis 4. Exercise 5. Nutritional supplements 1. Massage 2. Acupressure 4. Exercise 5. Nutritional supplements The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage? Standard Text: Select all that apply. 1. Supine 2. Fowler's 3. Trendelenburg 4. Prone 5. Side-lying 4. Prone 5. Side-lying A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. The nurse realizes this care should be provided by 1. the registered nurse. 2. unlicensed assistive personnel. 3. no one, because the client cannot assume the prone position. 4. the physician. 1. the registered nurse. The nurse wants to assign back rubs to unlicensed assistive personnel (UAP). Before doing so, the nurse should first determine whether Standard Text: Select all that apply. 1. unlicensed assistive personnel know how to perform a back rub. 2. there any clients who have intravenous fluids infusing. 3. there any clients who should not have a back rub performed. 4. there any clients who are prescribed to take nothing by mouth. 5. there any clients who do not want a back rub done by unlicensed assistive personnel. 1. unlicensed assistive personnel know how to perform a back rub. 3. there any clients who should not have a back rub performed. 5. there any clients who do not want a back rub done by unlicensed assistive personnel. The nurse has completed a back massage for a client. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Effectiveness of pain medication using a rating scale from 0 to 10 2. Position to perform the massage 3. Content of communication that occurred during the back massage 4. Amount of lotion used during the back massage 5. Client response 2. Position to perform the massage 5. Client response A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client? 1. Apply ice to the knee over the cast. 2. Rub the knee of the non-casted leg. 3. Apply heat to the knee over the cast. 4. Rub the foot of the casted extremity. 2. Rub the knee of the non-casted leg. A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the client's pain was influenced by which type of distraction? 1. Visual 2. Tactile 3. Intellectual 4. Behavioral 1. Visual The health care provider is writing medication orders for a client recovering from spinal fusion surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should the nurse consider providing to the client? Standard Text: Select all that apply. 1. Oxymorphone (Opana) 2. Hydrocodone (Vicodin) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid) 1. Oxymorphone (Opana) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid) The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client? Standard Text: Select all that apply. 1. Secure all tubing connections with gauze. 2. Apply tape over all injection ports on the tubing. 3. Cleanse the insertion site with alcohol swabs once a day. 4. Label the tubing, infusion bag, and pump with the word "epidural." 5. Post a sign above the client's bed indicating that an epidural is being used. 2. Apply tape over all injection ports on the tubing. 4. Label the tubing, infusion bag, and pump with the word "epidural." 5. Post a sign above the client's bed indicating that an epidural is being used. Define Culturally responsive care. Care that is centered on the clients cultural point of view and integrates the clients values and beliefs into the plan of care. Culture a set of values, beliefs, and attitudes shared among a group of people Subculture Composed of ppl who have a distinct identiy and are related to a larger cultural group Multiculture A person who has multiple patterns of identification or crosses several cultures , lifestyle, and sets of values. Heritage Things passed down from previous generations Diversity Fact or state of being different Race White, african american..etc Nationality State/country a person is born/has membership Religion A system of beliefs, practices, and ethical values worshipped as the creator/ruler of universe Prejudice A preconceived notion or judgement not based on sufficient knowledge Racism Assumptions held a bout race Discrimination Negative treatment of individuals/groups based on their race, ethnicity and gender. Ethnocentrism Belief in the supeiority of ones own culture and lifestyle. What is health Disparities? What are the causes of health disparities The differences in care experienced by one population compared to another population What is health equity? The highest possible standard of health for all people, esp those at greatest risk for poor health What is the difference between acculturation and assimilation? Acculturation-when ppl incorporate traits from another culture Assimilation- process by which an individual develops a new cultural identity Define transcultural nursing Focuses on providing care within the differences and similarities of the beliefs , values , and patterns of culture Define the AACN 5 cultural competencies 1. Apply knowledge of social and cultural factors that affect nursing and healthcare across multiple contexts. 2. Use relevant data sources and best evidence in providing culturally competent care 3. Promote achievement of safe quality outcomes of care for diverse populations 4. Advocate for social justice 5. Participate in continuous cultural competency development. What is cultural competence? Having the knowledge, abilities, and skills to deliver care matching the patient's cultural beliefs and practices. The ongoing process in which the nurse continually strives to achieve the ability and availability to work effectively within the cultural context of the pt. Define folk medicine Illness prevention and healing that derive from cultural traditions. EXAMPLE: cultural traditions, special teas, herbs, "cures" How is communication and culture closely connected? Through communication the culture is transmitted from one generation to the next and knowledge about the culture is transmitted within the group and to those outside the group. What is the dfference betueen translator and interpreter? Translator: converts written material from one language to another. Interpreter: able to transform the message expressed in a spoken or signed source language into its target language. (From one spoken language to another) How is food preparation related to cultural practices? -how the foods prepped and served -weather to breastfeed vs. bottle feed -some foods "treat" illnesses -religious practice affects diet How can a Nurse develop self awareness in culturally responsive care? Must first understand own culture, beliefs, and assumptions and reflect on questions which focus on communicating and caring for diverse populations. How can a nurse convey cultural sensitivity? Spend time with clients and convey a genuine desire to understand their values and beliefs What is the LEARN acronym? -Listen actively with empathy to clients perception -Explain what you think you heard/clarify -Acknowledge importance of whats said/meaning -Recommend inclusive strategies -Negotiate the plan of care by collaborating with the client and others. How can we implement cultural nursing care? -cultural preservation and maintenance -cultural accommodation and negotiation How can families play a role in culturally responsive care? -cultural assessment of client and family -learn rituals, customs, and practices -dont make assumptions -recognize that it is the clients right (or families) to make their own -convey respect and cooperate with family Define teaching A system of activities intended to produce learning Define 3 ways a nurse may teach: -clients and families: one to one teaching -community: health education programs -health personnel: continuing education, in service programs and staff development Define learning A desire or a requirement to know something that is unknown to the learner Define compliance An Individuals desire to learn and to act on the learning Define adherence The degree to which clients follow the agreed on recommendations of healthcare providers What are the 3 Bloom domains? What are the difference in the 3? -Cognitive domain: "thinking" domain that includes 6 intellectual abilities and thinking processes beginning with knowing, comprehending, and applying to analysis, synthesis, and evaluation. -Affective domain: "feeling" domain, deals with personal issues such as attitudes, beliefs, behaviors and emotions. -Psychomotor domain: "skill" domain, includes fine and gross motor abilities. What is positive reinforcement? A pleasant experience s/o praise and encouragement What is motivation to learn? Example? -the desire to learn -example: clients with heart disease may need to know effects of smoking before they recognize the need to stop. What is readiness to learn? -The demonstration or cues that reflect the learners motivation to learn at a specific time. -Example: a client may want to learn self care during dressing change. What are barriers to learning? Example? -acute Illness. Ex: requires all resources to cope. -pain. Ex. Decreases ability to concentrate -prognosis. Ex. Unable to concentrate on info. -emotion. Ex. Anxiety, anger, depression -Age. Ex. Vision, hearing, motor impaired -culture/religion. Ex. Can place restrictions on care -physical disability Ex. Vision, hearing, sensory -mental disability. Ex. Impaired cognitive ability -biorhythms Ex. Mental/physical alters rhythm What are some factors that affect learning? -Age -health beliefs -culture -economic -clients understanding -learning style -support system What is "ask me three"? -is the client able to focus on things other than physical status? - is the client emotionally ready to learn self care activities? - can the client think clearly at this point? When developing written teaching aids, what language level should we keep the teaching? At or below 6th grade level List 5 special teaching strategies: -explanation or description- cognitive -one on one discussion- affective, cognitive -answering questions- cognitive -demonstration- psychomotor -practice- psychomotor Define transcultural teaching: A teaching/learning process including language and communication challenges, time, cultural healing practices, beliefs, and high risk health problems.. Why do we document the teaching process? Provides a legal record that the teaching took place and communicates the teaching to other health professionals. Name 3 cultures that value family inclusion. What are the advantages/disadvantages? -Hispanic/Latino American: important for the nurse to direct teaching to include all interested family members. -Decisions are usually made by male and older members of the family -ensure adequate physical space to allow room for all family members. -Black/African Americans: family structure traditionally bee matriarchal -important to recognize the central role that women have in decision making. -grandmothers have essential roles in family and may be involved in support -Asian/Pacific Islanders: Decision making is often a family matter. -Asians may agree or nod their heads in agreement to avoid being offensive or disruptive by disagreeing with nurse. - Nods DO NOT MEAN CONSENT. - May need to be given permission to ask questions. What is the pharmacopoeia? A book containing a list of products used in medicine, with the descriptions of the product, chemical tests for identity, purity , formulas and prescriptions. Define therapeutic effect: The desired effect of a medication, the primary effect, the intended reason a drug is prescribed. Define side effect: Secondary effect that is unintended. Side effects are usually predictable and may/may not be harmful. Define adverse effect: Severe side effects or reactions and may justify the discontinuation of a drug. Define drug toxicity: Harmful effects of a drug on an organism or tissue, results from overdosage, ingestion of a drug intended for external use, or buildup of the drug in the blood. Define Drug Allergy: An immunologic reaction to a drug, when a pt is first introduced to a foreign substance (antigen), the body may react by producing antibodies. Name and describe the 6 therapeutic actions of drugs? -Palliative : relieves symptoms of disease -Curative: cures a disease or condition -Supportive: supports body function until body responds -Substitutive: replaces body fluids or substances -Chemotherapeutic: destroys malignant cells -Restorative: returns the body to health What are some common mild allergic reactions? -skin rash - rhinitis (runny nose) -wheezing -pruritus (itching) -angioedema -eye tearing -N/V -dyspnea -diarrhea What is an anaphylactic reaction? A severe allergic reaction usually occurring immediately after administration of drug and can be fatal Define drug tolerance A unusually low physiological response to a drug and requires increases in the dosage to maintain a given therapeutic effect. Define drug half-life the time required for the amount of drugs in the body to decrease by 50% of what it was at initial administration. What are the key terms related to drug actions? What do these mean? Pharmacodynamics, receptor, agonist, antagonist? -Pharmacodynamics- the mechanism of drug action and the relationships between drug concentration and responses in the body. -Receptor-the drugs specific target -Agonist- when a drug produces the same response as the physiological or endogenous substance. -Antagonist- a drug that inhibits cell function by occupying receptor sites. What is Pharmacokinetics? -Absorption:process in which a drug passes into the bloodstream -Distribution: the transportation of a drug from its site of absorption to site of action. -Biotransformation: process by which a drug is converted to a less active form. EX. Metabolism or detoxification. -Excretion: process in which metabolites and drugs are eliminated from the body. What are some developmental factors affecting medication action? -older adults: decreased liver and kidney function, taking multiple drugs resulting in incompatibilities, beta blockers can cause confusion and dizziness What are some examples of gender factors that affect medication action? -body fat, fluid, and hormonal differences. - more studies have been done on men What are some examples of cultural, ethnic, and genetic factors that affect medication action? -genes that control liver metabolism vary -certain meds may work well at usual therapeutic dosages for certain ethnic groups but toxic for others. - herbal remedy may speed up or slow down metabolism of prescribed meds What are some examples of diet that effect medication action? -nutrients can effect action of a medication. What are some examples of time of admin that effect medication action? Some oral meds are absorbed more quickly if the stomach is empty; whereas other meds rapidly absorb when administered with food. What are the different routes of administration? -oral -buccal -sublingual -transdermal -sub-q -topical -IM -ID -IV -inhalation -rectal -vaginal Define the following routes: Oral, sublingual, buccal, parenteral, topical -Oral: swallowed -Sublingual: under the tongue -Buccal: in the cheek -Parenteral: by needle -Topical: applied to surface of body What are 4 types of Medication orders? Whats the difference? -Stat order: given immediately/at once -Single order: one time order -Standing order: may/may not have termination date -PRN order: as needed order What are the essential parts of a medication order? -Full name of client -Date and time orders wrote -Name of drug -Dosage of drug -Frequency -Route -Signature of person writing order What do you do if you believe an order is inappropriate? Question/Call the primary care provider How many ppl die annually from medication errors? -98,000 ppl Do you administer meds someone else prepared? No, you are responsible for your own actions. You didn't pull/prepare it?, you don't give it! What do you do when a med was omitted? Record the fact, with reason What do you do if a med error is made? Report to charge nurse and primary care provider Define medication reconciliation Creating the most accurate list of all meds a pt is taking and comparing that list to physicians admission. When do we do a med rec? -At admission -At discharge -At transfer Define the 6 step process of administering meds: ify client 2. Inform client 3. Administer drug 4. Provide help if needed 5. Record drug administered 6. Evaluate clients response What are the 3 med checks? 1. Reading Mar and pulling meds 2. While prepping meds 3. At bedside What are the 5 rights of medication administration? 1. right patient 2. right drug 3. right dose 4. right route 5. right time What does NPO mean? nothing by mouth When we use a pill splitter, what do we need to do between each medication/patient? Clean it. When we use a med cart to pass meds, what do we need to make sure of before leaving cart unattended? That the cart is locked! What are your 2 patient identifiers? Name and date of birth What are some lifespan considerations we need to consider when giving pts oral meds? -can the client swallow and retain the drug in stomach? ( give a drink if water) When handling a syringe, the nurse may touch the outside of the barrel and the handle of the plunger; must avoid what? Plunger, needle and vial top What is the scoop method? Recapping the needle without hands on cap until needle is inside cap What is an ampule? What do we use to withdraw the med from an ampule and why? -glass container designed to hold a single dose of a drug. -a filter needle, filter straw What is a vial? Whats the difference between a multi-dose vial and a single dose vial? -small glass bottle with sealed rubber cap -single dose doesn't increase volume -multi-dose does increase volume What is the term "clear before cloudy" related to? Regular insulin is clear and NPH insulin is cloudy due to proteins in insulin. What is the term "start low, go slow" related to? Older patients may require smaller doses of a drug because the drug and its metabolites may accumulate in the body. What angle do you give the following injections at? ID, SUB-Q, IM? ID- 5°-15° SUB-Q- 45°-90° IM- 90° What is preferred site for IM? Ventrogluteal What is the most fluid you can give in ID, IM and SUBQ? ID-0.1 mL IM- Deltoid=0.5- 1 mL/ Ventro=3mL SUBQ- 0.5-1 mL How much fluid can be given in the deltoid? 0.5 - 1mL What is the Z track method? This is used for IM injections. Use nondominant hand to pull skin laterally and hold it in position while giving injection. Release skin immediately after withdrawing needle to seal off the injection site. This prevents the medication from leaking through the more sensitive subcutaneous tissue from the muscle. Done at the ventrogluteal or dorsogluteal sites. What do we do if we get blood return when you aspirate on an IM injection? -Remove needle, discard, reprepare and administer med. What size gauge is used for intradermal? What is it used for? How long it is? What angle is it given? #25-27 gauge Used for TB/allergy testing 1/4 - 5/8 5°-15° What size gauge is used for SUBQ? What is it used for? How long it is? What angle is it given? #25-30 Used for Insulin 3/8 - 5/8 45° - 90° What size gauge is used for IM? What is it used for? How long it is? What angle is it given? Deltoid- #23-25 Ventrogleuteal- #21-22 When meds needs to be absorbed quickly 1 - 1.5 inch long 90° What do we typically flush and IV with? A saline flush is a mixture of salt and water that is compatible with body's fluids and tissues. It is used to push any residual medication or fluid through the IV line and into your vein. This keeps the PIV line clean and reduces the risk of infection or occlusion. What is a topical medication? Topical medications are medications applied onto the body to treat various ailments. Most commonly, a topical drug delivery system is applied to the skin, where the medicine either treats only the area of application or is absorbed into the bloodstream through the dermis. -topical administration means application to body surfaces such as the skin or mucous membranes to treat ailments via a large range of classes including creams, foams, gels, lotions, and ointments. What is a transdermal patch? Transdermal patches is a system that administers sustained action medications (nitroglycerin, estrogen, and nicotine) via multilayered films containing the drug and adhesive layer. What do we need to make sure we do when applying a nicotine patch? Wear gloves to avoid getting medication on skin. Do not apply to breast (women) Time date and initial before applying patch What do we need to make sure we do when applying a opiate pain patch? Time, date, and initial before applying patch Wear gloves to avoid getting medication on skin. Clean area with soap and water Select a clean dry area free of hair and matches the manufacturer's recommendations. Do not apply to skin with cuts or lacerations. 2nd nurse to witness application/discard When we receive a verbal or telephone order from a primary care provider, what do we need to do when we have received it to make sure it is accurate? Read it back to Primary care provider.. Clients Full name Date and time order is written Name of drug to be administered Dosage of the drug Frequency of administration Route of administration Signature of the person writing the order How do we instill Ophthalmic drops? dropper 1-2 cm above the sac. Or Holding the tube above the lower conjunctival sac, squeeze 2cm of ointment from the tube into the lower conjunctival sac from the inner canthus outward. How do we instill otic drops? For Adults pull pinna upward and backward For children under 3 pull pinna down and back What position does the patient need to be in when instilling vaginal medications? Assist client to a back lying position with the knees flexed and the hips rotated laterally. What position does the patient need to be in when instilling rectal medications? Assist client to a left lateral or a left sims position with the upper leg flexed. What is a meter dose inhaler? What do we need to make sure the patient does after administering to prevent infection? A pressurized container of medication that can be used by the client to release the medication through a mouthpiece. Need to make sure the patient rinses their mouth with water after use, to remove any remaining medication. What is a spacer? A spacer Can be attached to the mouthpiece to facilitate medication absorption for better results. Spacers are holding chambers into which the medication is fired and from which the patient inhales, so that the dose is not lost by exhalation. What is a lavage? (irrigation) is the washing out of a body cavity by a stream of water or other fluid that may or may not be medicated. Define pain. with actual or potential tissue damage or described in terms of such damage. Define pain management. The alleviation of pain or a reduction in pain to a level of comfort that is acceptable What are 4 types of pain? 1. location 2. duration 3. intensity 4. etiology What is referred pain? Pain may also be referred (appear to arise in different areas) to other parts of the body. For example, cardiac pain may be felt in the shoulder or left arm, with or without chest pain. Define visceral pain. Visceral pain(pain arising from organs or hollow viscera) is often perceived in an area remote from the organ causing pain. What is acute pain? When pain lasts only though the expected recovery period, it is described as acute pain, weather it has a sudden or slow onset, regardless of its intensity. What is chronic pain? Chronic pain also known as persistent pain, is prolonged, usually recurring or lasting 3 months or longer, and interferes with functioning. Compare the clinical manifestations between acute and chronic pain. See table 46-1. Acute Pain Mild to severe Sympathetic nervous system Parasympathetic nervous responses: system responses: Increased pulse rate normal Increased respiratory rate Elevated blood pressure Diaphoresis Dilated pupils or dilated Related to tissue injury; beyond healing resolves with healing Client may be restless depressed and anxious Client reports pain Client may exhibit behavior indicative of pain: crying, rub area, holding area Comparison of Acute and Chronic Pain Chronic Pain Mild to severe Parasympathetic nervous system responses: Vital signs normal • Dry, warm skin Pupils normal or dilated Continues beyond healing Client is usually depressed and withdrawn Client often does not mention pain unless asked Pain behavior often absent What is cancer pain? Cancer pain may result from the direct effects of the disease and its treatment, or it may be unrelated. Over time, other diagnoses have been added to the "malignant pain" category. Describe the different intensity of pain. 0-10 scale 1-3 is mild pain 4-6 is moderate pain 7-10 is severe pain Nociceptive pain- experienced when an intact properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care. For example, the pain experienced following a cut or broken bone alerts the person to avoid further damage until tit is properly healed. Somatic pain- originates in the skin muscles bone or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain. Neuropathic pain- is associated with damaged or malfunctioning nerves due to illness (post herpetic neuralgia, diabetic peripheral neuropathy), injury (phantom limb pain, spinal cord injury pain), or undetermined reasons. Neuropathic pain is typically chronic, it is described as burning "electric shock" and or tingling, dull aching. Episodes of sharp shooting pain can also be experienced. Neuropathic pain tends to be difficult to treat. Peripheral neuropathic pain- (phantom limb pain, carpal tunnel syndrome) follows damage or sensitization of peripheral nerves. What is pain threshold? Pain threshold Is the least amount of stimuli that is needed for a person to label a sensation as pain. What is pain tolerance? Is the maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of the pain or relief. Pain tolerance varies considerably from person to person. What is post-herpetic neuralgia? This condition, which currently affects 2 million American's, occurs when a case of herpes zoster (shingles) typically erupts decades after a primary infection (chickenpox) during a period of stress or compromised immune functioning. What is phantom pain? this sensation is painful, and it may occur spontaneously, or is evoked (poor fitting prosthesis). What is trigeminal neuralgia? This is the intense stab like pain that is distributed by one or more branches of the trigeminal nerve (fifth cranial) The pain is usually experienced on parts of the face and head. It is also so severe that it produces facial muscle spasms. Describe Gate Control Theory. This theory suggests that the spinal cord contains a neurological "gate" that either blocks pain signals or allows them to continue to the brain. Describe the 3 types of pain stimuli. Stimulus Type MECHANICAL 1. Teums to body tise ) 2. Alterations in body tissues e.g. edema 3. Bockage of a body duct 4. Tumor 5. Muscle spasm THERMAL Extreme heat or cold e.g. burns CHEMICAL 1. Tissue ischemia e.g. biocked coronary artery 2. Muscle spasm Factors affecting the pain experience. Define the differences: Ethnic and cultural views Developmental stage Environment and support people Previous pain experience Ethnic and cultural views narsing Cultural background can affect the level of pain that an individual is willing to tolerate. Individuals in one culture may learn to be expressive about pain, whereas another culture may have learned to keep those feelings to themselves. Nurses must realize their own attitudes and expectations about pain. Nurses may be unaware and emotionally apathetic toward a certain culture/ethnicity. Nurses must become competent and knowledgeable about differences in meaning of an appropriate response to pain. Factors affecting the pain experience. Define the differences: Ethnic and cultural views Cultural background can affect the level of pain that an individual is willing to tolerate. Individuals in one culture may learn to be expressive about pain, whereas another culture may have learned to keep those feelings to themselves. Nurses must realize their own attitudes and expectations about pain. Nurses may be unaware and emotionally apathetic toward a certain culture/ethnicity. Nurses must become competent and knowledgeable about differences in meaning of an appropriate response to pain. espo Factors affecting the pain experience. Define the differences: Developmental stage Children may be less able than an adult to articulate their experience or needs related to pain, which may result in their pain being undertreated. However, children as young as 3 years, if evaluated properly, can accurately report the location and intensity of their pain. With puberty comes the emergence of some pain syndromes, particularly in young women. Including headaches, fibromyalgia, lupus, and menstrual related disorders. Older adults constitute the largest group of individuals seeking health care services. The prevalence of pain in the older population is generally higher due to both acute and chronic disease conditions. Factors affecting the pain experience. Define differences: pain than people without experience. The success or the lack of success of pain relief measures influences person's expectations for relief and future response to interventions. For example, a person who has tried several nondrug pain relief measures without success may have little hope about the helpfulness of nursing interventions and may demand medication as the only thing that helps the pain. Age variations in the pain experience. How might the older adult perceive pain and their behavior? May perceive pain as part of the aging process. May withhold statements of pain because of fear of treatment or lifestyle changes in becoming dependent. . . What is the Wong Baker Faces Scale? Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is leeling. Rating scale is recommended for persons age 3 years and older. Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes own pain and record the appropriate number. Ertect on Activities of Daily Living Sleep • Appetite • Concentration • Work/school Interpersonal relationships • Matital relationssex • Home activities • Driving/walking • Lesiare activities • Emotional status (mood, irritability depression, axiety) used to determine the degree of alteralion in ADLA A rating scale of none. a little, or a gret deal, or another range What are some barriers to pain management? be done or that the pain is not severe enough. Exaggerated fear of becoming addicted, especially when long term opioid use is prescribed. What is a nonopioid/nsaid? Non-Steroidal Anti-inflammatory Drug NSAIDS relieve pain by inhibiting the enzyme cyclooxygenase (COX) a chemical that is activated by damaged tissue, resulting in decreased synthesis of prostaglandins. Used to treat mild pain and fever What are some nonopioid/nsaid side effects? Hives, face swelling, shock asthma, GI bleeding, Tinnitus What are the 3 primary types of opioids? Full agonists-these pure opioid drugs bind tightly to mu receptor sites, producing maximum pain inhibition, an agonist effect. to a patient who has not taken any pure opioids. However, they can act like opioids and relieve pain (agonist effect) when given Mixed Agonists-antagonist. Agonist-antagonist analgesic drugs Includes Morphine, oxycodone, Percocet, dilaudid and fentanyl. can block or inactivate other opioid analgesics when given to a effect (Antagonist effect). These drugs include, Dalgan, Talwin, pt. who has been taking pure opioids, creating a withdrawal and Nubain. Partial Agonists-have a ceiling effect in contrast to a full the mu receptors or are neutral at that receptor but bind at a agonist. These drugs such as buprenorphine (Suboxone) block kappa receptor site. What are some misconceptions about nonopioids? Misconception Clents experience severe pein only when they have had major surgery The nurse or other health care professionals are the authorities The about a cleni's pain. Administering analgesics regularty for pain will lead to addiction. The amount of tiesue damage is directly related to the amount pain. Visible physiological or behavioral signs accompany pain and can be used to verify its existence. What are some opioid side effects? Respiratory depression, sedation, nausea, vomiting, urinary retention, blurred vision, sexual dysfunction, and constipation. The most concerning adverse effect of opioids is respiratory depression, (8 breaths a minute or less). The patient will appear overly sedated, and respirations will be slow and deep with periods of apnea. What is a placebo? Are we allowed to administer a placebo? be void of any known therapeutic value". An example would A placebo is "any sham medication or procedure designed to be a sugar pill or an injection of saline. A placebo is a pill, injection or thing that appears to be a medical treatment but isn't. What is a PCA? Patient Controlled Analgesia (PCA) Is an interactive method of pain management that permits clients to treat their pain by self-administering doses of analgesics. What are some examples of nonpharmacologic pain management? Cutaneous stimulation, ice, or heat., immobilization or therapeutic exercises, transcutaneous electrical nerve stimulation (TENS), and acupuncture. Mind body (cognitive behavioral) interventions include distracting activities, relaxation techniques, imagery mediation, biofeedback, hypnosis, cognitive reframing, emotional counseling, and spiritually directed approaches. Define loss. Loss is an actual or potential situation in which something that is valued is changed or no longer valued. Define actual loss, perceived loss, and anticipatory loss. Perceived loss- is experienced by one person but cannot be verified by others. Anticipatory loss- is experienced before the loss actually occurs. Define the loss of aspect of self. Losing an aspect of self-changes, a person's body image, even though the loss may not be obvious. A face scarred from a burn is generally obvious, loss of a part of the stomach or loss of the ability to feel emotion may not be as obvious. Define the loss of external objects. Loss of external objects includes loss of inanimate objects that have importance to the person, such as losing money or the burning down of a family house and loss of animate (live) objects such as pets that provide love and companionship. Define the loss of familiar environment. Separation from an environment and people who provide security can cause a sense of loss. Define the loss of loved ones. Losing a loved one or valued person through illness, divorce, separation, or death ca be very disturbing. In some illnesses (Alzheimer's) a person may undergo personality changes that make friends and family feel they have lost that person. The death of a loved one is a complete and permanent loss. Define Grief, Bereavement and Mourning. -Grief is the total response to the emotional experience related to loss. Grief is manifested in thoughts, feelings, and behaviors associated with overwhelming distress or sorrow. -Bereavement is the subjective response experienced by the surviving loved ones. -Mourning is the behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs and custom. Define anticipatory grief. such as the wife who grieves before her ailing husband Anticipatory grief is experienced in advance of the event dies. Define disenfranchised grief Disenfranchised grief occurs when a person is unable to acknowledge the loss of other people. Situations in which this may occur often relate to a socially unacceptable loss that cannot be spoken about, such suicide, abortion, or giving a child up for adoption. Define complicated grief. Complicated grief exists when the strategies to cope with the loss are maladaptive and out of proportion or inconsistent with cultural, religious, or age-appropriate norms. Many factors can contribute to complicated grief, including a prior traumatic loss, family or cultural barriers to the emotional expression of grief, sudden death, strained relationships between the survivor and the deceased, and lack of adequate support for the survivor. What are some factors that influence the loss and grief responses? Age, significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, support systems, and the cause of the loss or death. What is "significance of the loss"? Depending on the person, one may experience a great sense of loss over divorce, another may find it only mildly disrupting. Several factors affect the significance of the loss: Importance of the lost person, object, or function Degree of change required because of the loss The persons beliefs and values How can culture influence reaction to loss? Culture influences an individual's reaction to loss. How grief is expressed is often determined by the customs of the culture. Some individuals believe that grief is a private matter to be endured internally. Some cultural groups value social support and the expression of loss. Expressions of grief through wailing, crying, physical prostration and other outward demonstrations are acceptable and encouraged. l Other groups may frown on this demonstration as a loss of control, favoring a more quiet and stoic expression of grief. Responses to death and dying: Grieving-denial, guilt, anger, despair, feelings of worthlessness, crying, and inability to concentrate. Fear-the feeling of disruption related to an identifiable source (in this case someone's death), crying, immobility, increased pulse and respirations, dry mouth, anorexia, difficulty sleeping, and nightmares. Hopelessness- occurs when the person perceives no solutions to the problem-when death becomes inevitable, and the person cannot see how to move beyond the death. Nurse may observe apathy, spessimism, and inability to decide. dth Powerlessness - A person who perceives a solution to the problem but does not believe that it is possible to implement the solution may be said to experience powerlessness. This loss of control may be manifested by anger, violence, acting out, depression and passive behavior. pen What is the definitions and signs of death? The traditional clinical signs of death were cessation of the apical pulse, respirations, and blood pressure, also referred to as heart-lung death. Since the artificial means to maintain respirations and blood circulation, in 1968 the following guidelines were adopted: Total lack of response to external stimuli No muscular movement, especially breathing No reflexes Flat encephalogram (brain waves) How can beliefs about preparation of the body, autopsy, organ donation, cremation, and prolonging life differ among different cultures/religions? Buddhist in America consider it an act of mercy and encourage it. In general the most significant factor decision to donate a family member's organs is how religious the consenter is. Cremation is discouraged, opposed, or prohibited by the Bahai, Mormon. Eastern Orthodox, Islamic, and Roman Catholic Faiths. Hindus in contrast, prefer cremation and cast the ashes in holy river. Prolongation of life is generally encouraged; However, some religions, such as Christian Science, are unlikely to recommend medical means to prolong life, and the Jewish faith generally opposes prolonging life after irreversible brain damage. In hopeless illness Buddhists may permit euthanasia. Nurses also need to be knowledgeable about the patient's death related rituals, such as last rites, chanting at the bedside, and other practices, such as special procedures for washing, dressing, positioning, shrouding, and attending the dead. What are the clinical manifestations of death? Signs of impending clinical death. Signs of Impending Clinical Death LOSS OF MUSCLE TONE Relaxation of the facial muscles (e.g., the jaw may sag) Difficulty speaking • Difficulty swallowing and gradual loss of the gag refiex Decreased activity of the nausea, accumulation of flatus, gastrointestinal tract, with subsequent abdominal distention, and reten- tion of feces, especially if narcotics or tranquilizers are being administered • Possible urinary and rectal incontinence due to decreased sphincter control • Diminished body movement SLOWING OF THE CIRCULATION • Diminished sensation Mottling and cyanosis of the extremities • Cold skin, first in the feet and later in the hands, ears, and nose (the client, however, may feel warm if there fever) • Slower and weaker pulse • Decreased blood pressure CHANGES IN RESPIRATIONS Rapid, shallow, irregular, or abnormally slow respirations Noisy breathing, referred to as the death rattle, due to collecting of mucus in the throat Mouth breathing, dry oral mucous membranes SENSORY IMPAIRMENT Blurred vision * Impaired senses of taste and smell What is hospice? Hospice care focuses on support and care of the dying person and family, with the goal of facilitating a peaceful and dignified death. Hospice is based on holistic concepts, emphasizes care to improve quality of life rather than cure, supports the client and family through the dying process, and supports the family through bereavement. Assessing the needs of the client's family is just as important as caring for the client who is receiving hospice care. What is palliative care? their families, including bereavement counselling, if indicated. Will enhance quality of life and may also positively influence the course of illness. Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. How do we meet the physiological needs of a dying client? provide physical, emotional, and spiritual comfort to relieve suffering What kind of nursing care can we do to meet those needs? Interventions include providing personal hygiene measures, controlling pain, relieving respiratory difficulties, assisting with movement, nutrition, hydration, and elimination, and providing measures related to sensory changes. How do we meet the spiritual needs of a dying client? Interventions include facilitating expressions of feeling, prayer, meditation, reading, and discussion with clergy or spiritual adviser. How do we prepare the body for the family to view? Can we delegate this? Soiled areas of the body are washed, However, a complete bath is not necessary, because the body will be washed by the mortician, a person trained in care of the dead. Absorbent pads are placed under the buttocks to take up anu feces and urine released because of relaxation of the sphincter muscles. A clean gown is placed on the client, and the hair is arranged. All Jewelry is removed, except a wedding band in some instances, which is taped to the finger. The top bed linens are adjusted neatly to cover the client to the shoulders. Soft lighting and chairs are provided for the family. What do we do with the body after the family has viewed it? After the family has viewed the body, if deceased is in the hospital setting the wrist identification band/tag is left on and additional identification tags are applied. The body is wrapped in a shroud, a large piece of plastic or cotton material used to enclose a body after death. Identification is then applied to the outside of the shroud. The body is taken to the morgue if arrangements have not been made to have mortician pick it up from the client's room. Nurses have a duty to handle the deceased with dignity and to label the corpse appropriately. What is a shroud? shroud, a large piece of plastic or cotton material used to enclose a body after death. What are large syringes used for? Irrigating and bolus feeding For NG tubes how should you make your meds? Crushable or open capsules Then dilute What do you dilute meds with for NG tube Warm sterile water How to give IV meds Clean the IV flush with saline Push meds slow Clean IV again Flush again How to give a rectal suppository? Left lateral or left sims position with upper leg flexed Lube gloved finger Insert med just past anal sphincter Ask pt to remain in positions for at least 5 mins How to give vaginal suppository Supine position Insert 8-10 cm Stay in position for 5-10 minutes