Med-Surg 1 (Exam 2 review) Questions and Answers with verified solutions

Med-Surg 1 (Exam 2 review) Questions and Answers with verified solutions A nurse is preparing a client for home care pain management following discharge. Which intervention does the nurse implement? A Discusses pain-relieving strategies on the day of discharge B Discusses home care only with the client's family, not with the client C Offers flexibility in home management of the client's current regimen D Offers information about end-of-life pain control management - ANS -C Flexibility will be necessary to adapt to the client's needs and allow for uninterrupted control of the client's pain issues. A cancer client is receiving low-dose oral morphine but is reporting both "breakthrough" pain and constipation. What intervention does the nurse implement? A Administers ordered docusate sodium (Colace) and gabapentin (Neurontin) B Decreases the morphine (morphine sulfate) dosage for the client C Gives the client a Fleet (sodium biphosphate) enema D Records the client's bowel movements - ANS -A Docusate is a stool softener, and gabapentin is an adjuvant for breakthrough pain. A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." How does the nurse respond? A "I will cancel your medication order." B "That sounds like a great plan; can you tell me more about it?" C "That sounds like a wonderful idea; and I think it will definitely work!'' D "Your plan will not work; people with your type of pain need narcotics.''" - ANS -B Complementary and alternative therapies should supplement, not replace, medication management. The nurse needs to obtain more data about the client's plan. A client had surgery two (2) days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 1 to 10 scale" of intensity. What intervention has the highest priority in the client's nursing care plan? A Encouraging diversional activities B Incorporating ADLs as soon as possible C Teaching key points of the relaxation response D Using preemptive analgesia - ANS -D Use of preemptive analgesia is a technique designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the hospital stay A client reports increasing pain during dressing changes. Which interventions does the nurse recommend for the client? Select all that apply. A Assistance by the client with the dressing change B Distraction C Epidural analgesic D Music therapy E Premedication F Transcutaneous electrical nerve stimulation (TENS) - ANS -B,D,E Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception. Efferent nerve fibers are stimulated. Premedication before painful client treatments is a good method of controlling pain during treatment. A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What does the nurse say to the visitor? A "Please allow the client to push the button when needed." B "Please don't touch any equipment in the client's room." C "Thank you. I am sure the client appreciated that." D "The client is asleep and is not in pain." - ANS -A The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues. A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical manifestations of pain. What does the nurse do next? A Decreases the client's standard pain medication dose B Gives the client a placebo and monitors the outcome C Gives the pain medication as requested D Withholds the pain medication - ANS -C Both types of chronic pain (chronic cancer pain and chronic non-cancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's responses when it is chronic cancer pain. A client with chronic arthritis pain tells the nurse, "I take 2 arthritis strength Tylenol (650 mg) every 8 hours." How does the nurse respond? "Aspirin would be a better, more effective choice for your pain relief." "More Tylenol is needed to provide effective pain relief for you." "That is the appropriate dose of Tylenol for your pain." "You will need to have routine liver and renal function laboratory tests. - ANS -D Clients taking Tylenol, especially high doses of it, should be reminded to have routine liver and renal function laboratory testing done. Hepatotoxicity and nephrotoxicity are adverse effects associated with long-term use. A client with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this client? A Adding acetaminophen (Tylenol) B Adding sertraline (Zoloft) as adjuvant therapy C Increasing the opioid dose to control the pain D Replacing the opioid with sertraline (Zoloft) for depression - ANS -B Both tricyclic and other antidepressants such as sertraline (Zoloft) help treat the depression that can accompany chronic pain. They also stimulate the activity of endogenous opiates (endorphins and enkephalins) by increasing levels of the neurotransmitter serotonin. Perhaps the greatest advantage of this group of drugs is their sedative effect. A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? A Addiction B Equianalgesia C Physical dependence D Pseudoaddiction - ANS -C Physical dependence occurs in everyone who takes opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms. A newly admitted client who was in an automobile accident has a concussion and is complaining of pain from a fractured femur and broken fingers. Which staff member does the charge nurse on the orthopedic unit assign to care for this client? A An experienced RN travel nurse who arrived on the unit this morning B An LPN/LVN who has worked on the orthopedic unit for 6 years C The neurology unit RN who has floated to the orthopedic unit D The RN orthopedic case manager who is responsible for discharge planning - ANS -C The neurology RN will have the skills and experience needed to assess the neurologic and orthopedic status of this client, as well as the client's pain status. A nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone (Dilaudid) IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What action does the nurse take initially? A Calls the care provider for a change in the medication order B Changes the order to every six (6) hours rather than every four (4) hours C Gives the client a dose of naloxone (Narcan) 0.4 mg IV D Performs a cognitive assessment on the client - ANS -C In an unresponsive client, the nurse should administer Narcan 0.4 mg (diluted in 10 mL) over a 2-minute time period to reverse the action of the opioid analgesic. A nurse is establishing a plan of care for a hospitalized client with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant? A Application of a transcutaneous electrical nerve stimulation (TENS) device B Education about nonpharmacologic interventions for pain control C Referral to available community resources for pain management D Use of conversation about the client's family to distract the client - ANS -D Distraction techniques such as conversation, music, and television may be implemented by unlicensed nursing staff members. A nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone (Percocet) orally for pain every 4 hours and is due to receive them at 4 PM. When does the nurse change the dressing? A 3:30 PM B 4:00 PM C 4:30 PM D 7:00 PM - ANS -C About 30 minutes after an analgesic is received is an optimal time to perform a procedure on a client. The opioid has had time to take effect and provide relief for the client. A nursing assistant reports that a client receiving PCA morphine is very drowsy and has a respiratory rate of 10 breaths/min. What is the nurse's best action at this time? A. Continue to monitor the client for further changes. B. Assess the client with a focus on sedation and respirations. C. Stop the PCA morphine infusion immediately. D. Call the physician to report the client's changes. - ANS -B Rationale: The nurse will need to perform his or her own assessment of the client with a focus on the client's reportedly low respiratory rate and drowsiness. The nurse cannot assume the ancillary staff's assessment is correct. Furthermore, drowsiness is an anticipated result of morphine administration. The client is demonstrating untoward effects from the morphine. The nurse should not stop the infusion of morphine until an assessment is performed. Although the nurse's assessment may eventually lead to a consultation with the physician, a thorough assessment of the client must be done first. A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. The nurse should immediately: A Repeat the PEF reading to verify the results. B Take the patient's vital signs. C Administer the rescue drugs. D Notify the patient's prescriber. - ANS -C Rationale: A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction. The patient needs to receive rescue drugs immediately, and then the prescriber should be notified. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs. A postoperative client is receiving epidural analgesia and reports itching. What does the nurse do next? A Gives a small amount of naloxone (Narcan) B Gives diphenhydramine (Benadryl) C Gives an antiemetic D Calls the surgeon - ANS -A Pruritus (itching) is a common side effect of epidural opioids and is first treated with a small amount of naloxone (Narcan). A postoperative client is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the client before administering the medication? A "Are you bleeding?" B "Are you really hurting every 4 hours?" C "Is your pain controlled between doses?" D "What do you do for pain when you're at home?" - ANS -C Asking the client about the frequency of pain and how the pain is being controlled helps in formulating an effective pain management plan. A postoperative client is vomiting and states, "I am having a lot of pain-about a 7 on a scale of 1 to 10." Which route of administration does the nurse choose to administer an analgesic to the client? A Intravenous B Oral C Rectal D Transdermal - ANS -A The intravenous route is the best choice for fast relief of nausea and pain. A postoperative client reports, "I have pain from a mild headache." Which PRN medication does the nurse administer? A Acetaminophen (Tylenol) B Hydromorphone (Dilaudid) C Midazolam (Versed) D Oxycodone hydrochloride w/acetaminophen (Tylox) - ANS -A Non-opioid analgesics such as Tylenol are the first line of therapy for mild to moderate pain. A postoperative client's arterial blood gas (ABG) values are pH 7.36, HCO3 21 mEq/L, Paco2 35 mm Hg, Pao2 98 mm Hg. What is the nurse's priority action? A. Compare these values with the client's preoperative ABG values. B. Assess the airway and notify the physician. C. Document the values as the only action. D. Increase the oxygen flow rate. - ANS -C Rationale: All of these ABG results are within the normal range and indicate adequacy of ventilation, gas exchange, and kidney function. Documentation is the only action that needs to be taken. After gastric surgery, a client arrives in the postanesthesia care unit (PACU). Which of these nursing actions is most appropriate for the RN to delegate to an experienced nursing assistant? A Monitor respiratory rate and airway patency. B Irrigate the nasogastric tube with saline. C Position the client on the left side. D Assess the client's pain level. - ANS -C This action can be delegated to a unlicensed care provider. An older woman is admitted to the unit after her emergency abdominal surgery on PCA morphine. She has early Alzheimer's disease and is attempting to pull out her IV line. What is the first method the nurse will use to assess this client's pain level? A. Ask her family or caregiver what they think her pain level is. B. Ask the client what her pain level is. C. Observe her body movements and facial expression. D. Assume she has pain and give her a bolus of PCA morphine. - ANS -D Rationale: It is important to be proactive in this situation and assume pain is present. The Checklist of Nonverbal Pain Indicators lists common pain indicators to observe and document: • Facial expression (e.g., grimacing, crying) • Verbalizations or vocalizations (e.g., screaming) • Body movements (e.g., restlessness) Based on the client's actions, the nurse can assume she is experiencing pain. A dose of morphine should be administered via the PCA pump, and the client's subsequent behavior should be assessed. If the client's agitated behavior is related to pain, agitation will decrease after the analgesia is administered. Although asking the family or caregiver what they think the client's pain level is should be incorporated into the plan of care, it is not likely the first method used by the nurse. Because of the client's Alzheimer's disease, she may not be able to comprehend the nurse's direct question about pain level or answer it accurately. An RN and an LPN/LVN are working together in caring for a client who needs all of the following actions after orthopedic surgery. Which actions would be best for the RN to accomplish? A Reinforce the need to cough and deep breathe every 2 to 4 hours. B Develop the discharge teaching plan in conjunction with the client.