NR 155 EXAM 2 (CHAPTER 36) WITH
CORRECT SOLUTION
The nurse is caring for a patient recovering from knee replacement surgery. The patient
complains of severe pain in the knee after receiving hydrocodone with acetaminophen
(Vicodin) 2 hours previously. What is the nurse's best action?
a. Administer another dose of the medication. b. Apply ice packs to the knee.
c. Apply heat packs to the knee.
d. Perform gentle range of motion. - ANSWER ANS: B
Application of cold decreases swelling and pain, produces local analgesia, and slows
nerve conduction, which improves functioning. Examples of cold therapy are ice bags
and cold compresses. The nurse should not administer another dose of medication
without an order from the provider. Heat will increase blood flow to the area rather than
reduce swelling. Gentle ROM will increase pain if done at this time.
The nurse is checking on the patient after administering pain medication 30 minutes
previously. Which assessment finding best indicates to the nurse that the pain
medication was effective?
a. The patient is sleeping quietly.
b. The patient states a reduction of the pain.
c. The patient's respirations are slow and regular.
d. The patient's blood pressure has returned to baseline. - ANSWER ANS: B
The best way for the nurse to determine that the pain medication was effective is for the
patient to state a reduction of the pain. The other assessment findings cannot
definitively determine whether the patient is still in pain.
The nurse is caring for a patient who has severe abdominal pain caused by acute
cholecystitis. The nurse recognizes which type of pain is this patient experiencing?
a. Visceral pain
b. Somatic pain
c. Radiating pain
d. Referred pain - ANSWER ANS: A
, Visceral pain arises from the organs of the body and occurs when inflammation and
tissue damage occur, such as with cholecystitis. Somatic pain occurs when there is
tissue damage to skin, muscle, joints, and bones. Referred pain occurs when the
discomfort is felt at a location other than the origin of the pain. Radiating pain extends to
another area of the body.
The nurse knows which is the best pain medication option for a patient to manage
severe long-term cancer pain at home?
a. Fentanyl (Duragesic) 50 mcg transdermal patch q 72 hours
b. Meperidine (Demerol) 50 mg IM q 6 hours c. Hydromorphone (Dilaudid) 0.2 mg q 10
minutes IV via PCA pump
d. Hydromorphone (Dilaudid) 0.08 mg/hour infusion through epidural catheter -
ANSWER ANS: A
An opioid transdermal patch is the best pain management option for home use with
patients who have long-term, severe cancer pain as no injections are required and the
opioid is slowly released over 72 hours. Epidurals and PCA pumps are intended for
hospital use. Frequent IM injections require nursing administration, are not comfortable
for the patient and are not optimal for chronic long-term pain.
The nurse is caring for a patiNent wRithIsevGereBc.hrConicMpain and applied the first
50 mcg transdermal fetanyl (Duragesic) patch 2 hours ago. The patient states that the
pain is presently rated at 9 on a 1 to 10 scale. What is the nurse's best action?
a. Instruct the patient that the fentanyl patch will start to work soon.
b. Check the provider's orders for a short-acting narcotic medication to administer for
breakthrough pain.
c. Give the patient a gentle back rub and encourage guided imagery.
d. Apply a second 25-mcg transdermal fentanyl patch now. - ANSWER ANS: B
Transdermal administration of medication does not become effective for 12 to 16 hours
after application. Short-acting narcotic medication should be given in the meantime to
make the patient comfortable.
The nurse is caring for a patient who has been taking ibuprofen (Motrin) 800 mg TID for
the last several months to relieve knee pain from arthritis. Which assessment finding
must be reported by the nurse to the provider promptly?
a. The patient has abdominal pain and pale skin.
b. The patient has constipation and takes stool softeners daily.
c. The patient enjoys a glass of wine every Friday and Saturday evening
CORRECT SOLUTION
The nurse is caring for a patient recovering from knee replacement surgery. The patient
complains of severe pain in the knee after receiving hydrocodone with acetaminophen
(Vicodin) 2 hours previously. What is the nurse's best action?
a. Administer another dose of the medication. b. Apply ice packs to the knee.
c. Apply heat packs to the knee.
d. Perform gentle range of motion. - ANSWER ANS: B
Application of cold decreases swelling and pain, produces local analgesia, and slows
nerve conduction, which improves functioning. Examples of cold therapy are ice bags
and cold compresses. The nurse should not administer another dose of medication
without an order from the provider. Heat will increase blood flow to the area rather than
reduce swelling. Gentle ROM will increase pain if done at this time.
The nurse is checking on the patient after administering pain medication 30 minutes
previously. Which assessment finding best indicates to the nurse that the pain
medication was effective?
a. The patient is sleeping quietly.
b. The patient states a reduction of the pain.
c. The patient's respirations are slow and regular.
d. The patient's blood pressure has returned to baseline. - ANSWER ANS: B
The best way for the nurse to determine that the pain medication was effective is for the
patient to state a reduction of the pain. The other assessment findings cannot
definitively determine whether the patient is still in pain.
The nurse is caring for a patient who has severe abdominal pain caused by acute
cholecystitis. The nurse recognizes which type of pain is this patient experiencing?
a. Visceral pain
b. Somatic pain
c. Radiating pain
d. Referred pain - ANSWER ANS: A
, Visceral pain arises from the organs of the body and occurs when inflammation and
tissue damage occur, such as with cholecystitis. Somatic pain occurs when there is
tissue damage to skin, muscle, joints, and bones. Referred pain occurs when the
discomfort is felt at a location other than the origin of the pain. Radiating pain extends to
another area of the body.
The nurse knows which is the best pain medication option for a patient to manage
severe long-term cancer pain at home?
a. Fentanyl (Duragesic) 50 mcg transdermal patch q 72 hours
b. Meperidine (Demerol) 50 mg IM q 6 hours c. Hydromorphone (Dilaudid) 0.2 mg q 10
minutes IV via PCA pump
d. Hydromorphone (Dilaudid) 0.08 mg/hour infusion through epidural catheter -
ANSWER ANS: A
An opioid transdermal patch is the best pain management option for home use with
patients who have long-term, severe cancer pain as no injections are required and the
opioid is slowly released over 72 hours. Epidurals and PCA pumps are intended for
hospital use. Frequent IM injections require nursing administration, are not comfortable
for the patient and are not optimal for chronic long-term pain.
The nurse is caring for a patiNent wRithIsevGereBc.hrConicMpain and applied the first
50 mcg transdermal fetanyl (Duragesic) patch 2 hours ago. The patient states that the
pain is presently rated at 9 on a 1 to 10 scale. What is the nurse's best action?
a. Instruct the patient that the fentanyl patch will start to work soon.
b. Check the provider's orders for a short-acting narcotic medication to administer for
breakthrough pain.
c. Give the patient a gentle back rub and encourage guided imagery.
d. Apply a second 25-mcg transdermal fentanyl patch now. - ANSWER ANS: B
Transdermal administration of medication does not become effective for 12 to 16 hours
after application. Short-acting narcotic medication should be given in the meantime to
make the patient comfortable.
The nurse is caring for a patient who has been taking ibuprofen (Motrin) 800 mg TID for
the last several months to relieve knee pain from arthritis. Which assessment finding
must be reported by the nurse to the provider promptly?
a. The patient has abdominal pain and pale skin.
b. The patient has constipation and takes stool softeners daily.
c. The patient enjoys a glass of wine every Friday and Saturday evening
