NUR 310 EXAM QUESTIONS AND
ANSWERS
The nurse is employing gate theory in the care of a client with pain in the lower back.
What actions by the nurse may assist in pain relief for the client?
Administer opioid analgesics
Use massage and heat application to the lower back
Encourage the client to have an epidural steroid injection
Have the client perform active exercises to stretch the back muscles - Answer-Use
massage and heat application to the lower back
When asking an older adult client about abdominal pain, the client reports, "I do not
want to be a bother because nothing hurts too much." The nurse notes that the client
grimaces and splints the abdomen when moving. What is the appropriate nursing
action?
Confirm that age is the reason for many types of pain.
Gently mention that the client appears to be experiencing pain that can be treated.
Remind the client that pain can be tolerated instead of using addictive pain medication.
Document the client's statement, and do nothing further. - Answer-Gently mention that
the client appears to be experiencing pain that can be treated.
A postoperative vaginal hysterectomy client complains of pain that is more intense than
this morning. This factor should be explained to the client as
"You will need more pain medication as the days progress."
"Your present pain is worse because you had your packing removed."
"I will call your doctor because you may have loosened sutures when walking."
"Acute pain tends to increase during the day and is called a routine pain response" -
Answer-"Acute pain tends to increase during the day and is called a routine pain
response"
A client reports after a back massage that his lower back pain has decreased from 8 to
3 on the pain scale. Which opioid neuromodulator does the nurse know is released with
skin stimulation and is more than likely responsible for this increased level of comfort?
Melatonin
Serotonin
Endorphins
Dopamine - Answer-Endorphins
The nurse is conducting an admission assessment, and asks the client what medication
is taken for pain. The client responds, "I take a little white pill to control my pain, but I
don't know the name of it," and presents the nurse with a plastic baggie full of white
pills. What is the priority nursing intervention?
Tell the healthcare provider that the client is unsure of the pain medication taken.
Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.
,Document what the client states.
Call the pharmacy to attempt to identify the pill. - Answer-Ask the client if he or she has
the bottle the drug was dispensed in from the pharmacy.
The nurse preparing to admit a client receiving epidural opioids should make sure that
which of the following medications is readily available on the unit?
Naloxone
Digoxin
Furosemide
Lisinopril - Answer-Naloxone
A nurse consults with a nurse practitioner trained to perform acupressure to teach the
method to a client being discharged. What process is involved in this pain relief
measure?
Cutaneous stimulation
Biofeedback mechanism
Patient-controlled analgesia (PCA)
Guided imagery - Answer-Cutaneous stimulation
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the
administration of an opioid anesthesia, the nurse observes the client's respiratory rate
decrease to 8 breaths per minute. What is the priority action by the nurse?
Begin CPR
Administration of 0.4 mg of naloxone
Place the client in the supine position
Administer a lower dose of the analgesic for the next dose - Answer-Administration of
0.4 mg of naloxone
A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such
as grimacing and guarding. Which is the most reliable method for assessing the client's
pain?
Compare the client's presentation to expected outcomes at this point in recovery.
Correlate the client's vital signs with their symptoms.
Assess and document the client's behaviors over a period of hours.
Ask the client to describe and rate their pain. - Answer-Ask the client to describe and
rate their pain.
Two hours after receiving a pain medication, the client reports still suffering from pain.
Which response is most appropriate?
"Have you ever had pain like this before?"
"Tell me where your pain is located."
"Do you need your pain medication now?"
"Tell me more about your pain." - Answer-"Tell me more about your pain."
The nurse implements cutaneous stimulation for a client as part of a strategy for pain
relief. Which nursing action exemplifies the use of this technique?
, The nurse gives the client a massage before bed.
The nurse teaches the client deep-breathing techniques for relaxation.
The nurse assists the client to focus on something pleasant rather than on pain.
The nurse plays soft music in the client's room. - Answer-The nurse gives the client a
massage before bed.
The nurse is caring for a client whose pain is being treated with epidural analgesia.
Which nursing action is most appropriate?
The nurse should expect slight resistance during the removal of the epidural catheter.
If the client develops a headache, an opioid analgesic may be administered along with
the epidural analgesia.
The anesthesiologist/pain management team should be notified immediately if the
client's respiratory rate is below 10 breaths/min.
If a client is experiencing adverse effects, a peripheral IV line should be inserted to
allow immediate administration of emergency drugs, if warranted. - Answer-The
anesthesiologist/pain management team should be notified immediately if the client's
respiratory rate is below 10 breaths/min.
Which statement accurately describes a consideration when using a patient-controlled
analgesia (PCA) pump to relieve client pain?
This approach can only be used with oral analgesics.
A PCA pump must be used and monitored in a health care facility.
The pump mechanism can be programmed to deliver a specified amount of analgesic
within a given time interval.
The PCA pump is not effective for chronic pain. - Answer-The pump mechanism can be
programmed to deliver a specified amount of analgesic within a given time interval.
How should the nurse position the head of the bed for a client receiving epidural
opioids?
Reverse Trendelenburg
Trendelenburg
Elevated 30 degrees
Flat - Answer-Elevated 30 degrees
While providing a back massage, the nurse observes a reddened area on the client's
sacral area. Which action by the nurse is appropriate?
Stop the back massage immediately.
Massage the area using lotion.
Apply a warm compress to the area.
Document the finding. - Answer-Document the finding.
A postoperative client who has been receiving morphine for pain management is
exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has
the potential to reverse the respiratory-depressant effect of an opioid?
Naloxone
Atropine
ANSWERS
The nurse is employing gate theory in the care of a client with pain in the lower back.
What actions by the nurse may assist in pain relief for the client?
Administer opioid analgesics
Use massage and heat application to the lower back
Encourage the client to have an epidural steroid injection
Have the client perform active exercises to stretch the back muscles - Answer-Use
massage and heat application to the lower back
When asking an older adult client about abdominal pain, the client reports, "I do not
want to be a bother because nothing hurts too much." The nurse notes that the client
grimaces and splints the abdomen when moving. What is the appropriate nursing
action?
Confirm that age is the reason for many types of pain.
Gently mention that the client appears to be experiencing pain that can be treated.
Remind the client that pain can be tolerated instead of using addictive pain medication.
Document the client's statement, and do nothing further. - Answer-Gently mention that
the client appears to be experiencing pain that can be treated.
A postoperative vaginal hysterectomy client complains of pain that is more intense than
this morning. This factor should be explained to the client as
"You will need more pain medication as the days progress."
"Your present pain is worse because you had your packing removed."
"I will call your doctor because you may have loosened sutures when walking."
"Acute pain tends to increase during the day and is called a routine pain response" -
Answer-"Acute pain tends to increase during the day and is called a routine pain
response"
A client reports after a back massage that his lower back pain has decreased from 8 to
3 on the pain scale. Which opioid neuromodulator does the nurse know is released with
skin stimulation and is more than likely responsible for this increased level of comfort?
Melatonin
Serotonin
Endorphins
Dopamine - Answer-Endorphins
The nurse is conducting an admission assessment, and asks the client what medication
is taken for pain. The client responds, "I take a little white pill to control my pain, but I
don't know the name of it," and presents the nurse with a plastic baggie full of white
pills. What is the priority nursing intervention?
Tell the healthcare provider that the client is unsure of the pain medication taken.
Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.
,Document what the client states.
Call the pharmacy to attempt to identify the pill. - Answer-Ask the client if he or she has
the bottle the drug was dispensed in from the pharmacy.
The nurse preparing to admit a client receiving epidural opioids should make sure that
which of the following medications is readily available on the unit?
Naloxone
Digoxin
Furosemide
Lisinopril - Answer-Naloxone
A nurse consults with a nurse practitioner trained to perform acupressure to teach the
method to a client being discharged. What process is involved in this pain relief
measure?
Cutaneous stimulation
Biofeedback mechanism
Patient-controlled analgesia (PCA)
Guided imagery - Answer-Cutaneous stimulation
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the
administration of an opioid anesthesia, the nurse observes the client's respiratory rate
decrease to 8 breaths per minute. What is the priority action by the nurse?
Begin CPR
Administration of 0.4 mg of naloxone
Place the client in the supine position
Administer a lower dose of the analgesic for the next dose - Answer-Administration of
0.4 mg of naloxone
A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such
as grimacing and guarding. Which is the most reliable method for assessing the client's
pain?
Compare the client's presentation to expected outcomes at this point in recovery.
Correlate the client's vital signs with their symptoms.
Assess and document the client's behaviors over a period of hours.
Ask the client to describe and rate their pain. - Answer-Ask the client to describe and
rate their pain.
Two hours after receiving a pain medication, the client reports still suffering from pain.
Which response is most appropriate?
"Have you ever had pain like this before?"
"Tell me where your pain is located."
"Do you need your pain medication now?"
"Tell me more about your pain." - Answer-"Tell me more about your pain."
The nurse implements cutaneous stimulation for a client as part of a strategy for pain
relief. Which nursing action exemplifies the use of this technique?
, The nurse gives the client a massage before bed.
The nurse teaches the client deep-breathing techniques for relaxation.
The nurse assists the client to focus on something pleasant rather than on pain.
The nurse plays soft music in the client's room. - Answer-The nurse gives the client a
massage before bed.
The nurse is caring for a client whose pain is being treated with epidural analgesia.
Which nursing action is most appropriate?
The nurse should expect slight resistance during the removal of the epidural catheter.
If the client develops a headache, an opioid analgesic may be administered along with
the epidural analgesia.
The anesthesiologist/pain management team should be notified immediately if the
client's respiratory rate is below 10 breaths/min.
If a client is experiencing adverse effects, a peripheral IV line should be inserted to
allow immediate administration of emergency drugs, if warranted. - Answer-The
anesthesiologist/pain management team should be notified immediately if the client's
respiratory rate is below 10 breaths/min.
Which statement accurately describes a consideration when using a patient-controlled
analgesia (PCA) pump to relieve client pain?
This approach can only be used with oral analgesics.
A PCA pump must be used and monitored in a health care facility.
The pump mechanism can be programmed to deliver a specified amount of analgesic
within a given time interval.
The PCA pump is not effective for chronic pain. - Answer-The pump mechanism can be
programmed to deliver a specified amount of analgesic within a given time interval.
How should the nurse position the head of the bed for a client receiving epidural
opioids?
Reverse Trendelenburg
Trendelenburg
Elevated 30 degrees
Flat - Answer-Elevated 30 degrees
While providing a back massage, the nurse observes a reddened area on the client's
sacral area. Which action by the nurse is appropriate?
Stop the back massage immediately.
Massage the area using lotion.
Apply a warm compress to the area.
Document the finding. - Answer-Document the finding.
A postoperative client who has been receiving morphine for pain management is
exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has
the potential to reverse the respiratory-depressant effect of an opioid?
Naloxone
Atropine
