Summary NURS 3205 - Adult Health Exam 3 Study Guide.
A patient with a 3-day history of a stroke that left her confused and unable to
communicate returns from interventional radiology following placement of a
gastrostomy tube. The patient had been taking hydrocodone/APAP 5/325 up to
four tablets/day before her stroke for the past year to manage her arthritic pain.
The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1
tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most
appropriate?
1. No action is required by the nurse because the order is appropriate.
2. Request to have the order changed to around the clock (ATC) for the first 48
hours.
3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3h, prn.
4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of
pain.
- ans -2. Request to have the order changed to around the clock (ATC) for the first
48 hours.
. Place the following steps in the correct order for administration of patient-
controlled analgesia:
1. Insert drug cartridge into infusion device and prime tubing.
2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for
15 seconds and allow to dry.
3. Demonstrate to patient how to push medication demand button.
4. Secure connection and anchor PCA tubing with tape.
5. Instruct patient to notify a nurse for possible side effects or changes in the
severity or location of pain.
6. Insert needleless adapter into injection port nearest patient.
7. Apply clean gloves. Check infuser and patient-control module for accurate
labeling or evidence of leaking.
8. Program computerized PCA pump as ordered to deliver prescribed medication
dose and lockout interval.
1099
9. Attach needleless adapter to tubing adapter of patient-controlled module.
- ans -3, 5, 7, 1, 9, 2, 6, 4, 8;
,. When teaching a patient about transcutaneous electrical nerve stimulation
(TENS), which of the following represent an accurate description of the
nonpharmacological therapy? (Select all that apply.)
1. Turn TENS on before patient feels discomfort.
2. TENS works peripherally and centrally on nerve receptors.
3. TENS does not require a health care provider order.
4. Remove any skin preparations before attaching TENS electrodes.
5. Placing electrodes directly over or near the pain site works best.
- ans -2,4,5
. Match the characteristics on the left with the appropriate pain category on the
right.
Acute Pain Chronic Pain
A. Has a protective effect
B. Lasts more than 3 to 6 months
C. Usually has identifiable cause
D. Dramatically affects quality of life
E. Viewed as a disease
F. Eventually resolves with or without treatment
- ans -Acute pain: A, C, F; Chronic pain: B, D, E.
When a smiling and cooperative patient complains of discomfort, nurses caring
for this patient often harbor misconceptions about the patient's pain. Which of
the following is true?
A. Chronic pain is psychological in nature.
B. Patients are the best judges of their pain.
C. Regular use of narcotic analgesics leads to drug addiction.
D. Amount of pain is reflective of actual tissue damage.
- ans -B. Patients are the best judges of their pain.
A patient has just undergone an appendectomy. When discussing with the patient
several pain-relief interventions, the most appropriate recommendation would
be:
A. adjunctive therapy.
B. nonopioids.
C. NSAIDs.
D. PCA pain management.
,- ans -D. PCA pain management.
A postoperative patient is using PCA. You will evaluate the effectiveness of the
medication when:
A. you compare assessed pain w/baseline pain.
B. body language is incongruent with reports of pain relief.
C. family members report that pain has subsided.
D. vital signs have returned to baseline.
- ans -a. you compare assessed pain w/baseline pain.
Which of the following signs or symptoms in a patient who is opioid-naïve is of
greatest concern to the nurse when assessing the patient 1 hour after
administering an opioid?
1. Oxygen saturation of 95%
2. Difficulty arousing the patient
3. Respiratory rate of 12 breaths/min
4. Pain intensity rating of 5 on a scale of 0 to 10
- ans -2. Difficulty arousing the patient
A health care provider writes the following order for a patient who is opioid-naïve
who returned from the operating room following a total hip replacement:
"Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the
nurse takes the following action:
1. Calls the health care provider and questions the order
2. Applies the patch the third postoperative day
3. Applies the patch as soon as the patient reports pain
4. Places the patch as close to the hip dressing as possible
- ans -1. Calls the health care provider and questions the order
A patient is being discharged home on an around-the-clock (ATC) opioid for
postoperative pain. Because of this order, the nurse anticipates an additional
order for which class of medication?
1. Opioid antagonists
2. Antiemetics
3. Stool softeners
4. Muscle relaxants
- ans -3. Stool softeners
, A new medical resident writes an order for oxycodone CR 10 mg PO q2h prn.
Which part of the order does the nurse question?
1. The drug
2. The time interval
3. The dose
4. The route
- ans -2. The time interval
The nurse reviews a patient's medical administration record (MAR) and finds that
the patient has received oxycodone/acetaminophen (5/325), two tablets PO
every 3 hours for the past 3 days. What concerns the nurse the most?
1. The patient's level of pain
2. The potential for addiction
3. The amount of daily acetaminophen
4. The risk for gastrointestinal bleeding
- ans -3. The amount of daily acetaminophen
. When using ice massage for pain relief, which of the following is correct? (Select
all that apply.)
1. Apply ice using firm pressure over the skin.
2. Apply ice for 5 minutes or until numbness occurs.
3. Apply ice no more than 3 times a day.
4. Limit application of ice to no longer than 10 minutes.
5. Use a slow, circular steady massage.
- ans -1. Apply ice using firm pressure over the skin.
When repositioning an immobile patient, the nurse notices redness over the hip
bone. What is indicated when a reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage 3 pressure injury needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the
ischemic episode
- ans -4. Blanching hyperemia, indicating the attempt by the body to overcome
the ischemic episode
A patient with a 3-day history of a stroke that left her confused and unable to
communicate returns from interventional radiology following placement of a
gastrostomy tube. The patient had been taking hydrocodone/APAP 5/325 up to
four tablets/day before her stroke for the past year to manage her arthritic pain.
The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1
tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most
appropriate?
1. No action is required by the nurse because the order is appropriate.
2. Request to have the order changed to around the clock (ATC) for the first 48
hours.
3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3h, prn.
4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of
pain.
- ans -2. Request to have the order changed to around the clock (ATC) for the first
48 hours.
. Place the following steps in the correct order for administration of patient-
controlled analgesia:
1. Insert drug cartridge into infusion device and prime tubing.
2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for
15 seconds and allow to dry.
3. Demonstrate to patient how to push medication demand button.
4. Secure connection and anchor PCA tubing with tape.
5. Instruct patient to notify a nurse for possible side effects or changes in the
severity or location of pain.
6. Insert needleless adapter into injection port nearest patient.
7. Apply clean gloves. Check infuser and patient-control module for accurate
labeling or evidence of leaking.
8. Program computerized PCA pump as ordered to deliver prescribed medication
dose and lockout interval.
1099
9. Attach needleless adapter to tubing adapter of patient-controlled module.
- ans -3, 5, 7, 1, 9, 2, 6, 4, 8;
,. When teaching a patient about transcutaneous electrical nerve stimulation
(TENS), which of the following represent an accurate description of the
nonpharmacological therapy? (Select all that apply.)
1. Turn TENS on before patient feels discomfort.
2. TENS works peripherally and centrally on nerve receptors.
3. TENS does not require a health care provider order.
4. Remove any skin preparations before attaching TENS electrodes.
5. Placing electrodes directly over or near the pain site works best.
- ans -2,4,5
. Match the characteristics on the left with the appropriate pain category on the
right.
Acute Pain Chronic Pain
A. Has a protective effect
B. Lasts more than 3 to 6 months
C. Usually has identifiable cause
D. Dramatically affects quality of life
E. Viewed as a disease
F. Eventually resolves with or without treatment
- ans -Acute pain: A, C, F; Chronic pain: B, D, E.
When a smiling and cooperative patient complains of discomfort, nurses caring
for this patient often harbor misconceptions about the patient's pain. Which of
the following is true?
A. Chronic pain is psychological in nature.
B. Patients are the best judges of their pain.
C. Regular use of narcotic analgesics leads to drug addiction.
D. Amount of pain is reflective of actual tissue damage.
- ans -B. Patients are the best judges of their pain.
A patient has just undergone an appendectomy. When discussing with the patient
several pain-relief interventions, the most appropriate recommendation would
be:
A. adjunctive therapy.
B. nonopioids.
C. NSAIDs.
D. PCA pain management.
,- ans -D. PCA pain management.
A postoperative patient is using PCA. You will evaluate the effectiveness of the
medication when:
A. you compare assessed pain w/baseline pain.
B. body language is incongruent with reports of pain relief.
C. family members report that pain has subsided.
D. vital signs have returned to baseline.
- ans -a. you compare assessed pain w/baseline pain.
Which of the following signs or symptoms in a patient who is opioid-naïve is of
greatest concern to the nurse when assessing the patient 1 hour after
administering an opioid?
1. Oxygen saturation of 95%
2. Difficulty arousing the patient
3. Respiratory rate of 12 breaths/min
4. Pain intensity rating of 5 on a scale of 0 to 10
- ans -2. Difficulty arousing the patient
A health care provider writes the following order for a patient who is opioid-naïve
who returned from the operating room following a total hip replacement:
"Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the
nurse takes the following action:
1. Calls the health care provider and questions the order
2. Applies the patch the third postoperative day
3. Applies the patch as soon as the patient reports pain
4. Places the patch as close to the hip dressing as possible
- ans -1. Calls the health care provider and questions the order
A patient is being discharged home on an around-the-clock (ATC) opioid for
postoperative pain. Because of this order, the nurse anticipates an additional
order for which class of medication?
1. Opioid antagonists
2. Antiemetics
3. Stool softeners
4. Muscle relaxants
- ans -3. Stool softeners
, A new medical resident writes an order for oxycodone CR 10 mg PO q2h prn.
Which part of the order does the nurse question?
1. The drug
2. The time interval
3. The dose
4. The route
- ans -2. The time interval
The nurse reviews a patient's medical administration record (MAR) and finds that
the patient has received oxycodone/acetaminophen (5/325), two tablets PO
every 3 hours for the past 3 days. What concerns the nurse the most?
1. The patient's level of pain
2. The potential for addiction
3. The amount of daily acetaminophen
4. The risk for gastrointestinal bleeding
- ans -3. The amount of daily acetaminophen
. When using ice massage for pain relief, which of the following is correct? (Select
all that apply.)
1. Apply ice using firm pressure over the skin.
2. Apply ice for 5 minutes or until numbness occurs.
3. Apply ice no more than 3 times a day.
4. Limit application of ice to no longer than 10 minutes.
5. Use a slow, circular steady massage.
- ans -1. Apply ice using firm pressure over the skin.
When repositioning an immobile patient, the nurse notices redness over the hip
bone. What is indicated when a reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage 3 pressure injury needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the
ischemic episode
- ans -4. Blanching hyperemia, indicating the attempt by the body to overcome
the ischemic episode
