Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX Exam

Questions 1. Which postoperative client is manifesting the most serious negative effect of inadequate pain management? 1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort 2. Develops venous thromboembolism related to immobility caused by pain and discomfort 3. Refuses to participate in physical therapy because of fear of pain caused by exercises 4. Feels depressed about loss of function and hopeless about getting relief from pain 2. A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the staff nurses to assess their care of this client. 3. According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients? Select all that apply. 1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies 5. Long-acting oral opioids, especially in the immediate postoperative period, for continuous around-the-clock relief 6. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, or ketamine is recommended for postoperative pain 4. The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports “feeling pretty good, 46 except for the pain and stiffness in my joints when I first get out of bed.” Which member of the health care team would be the most appropriate to aid in the client's report of pain? 1. Health care provider to review the dosage and frequency of pain medication 2. Physical therapist for evaluation of function and possible exercise therapy 3. Social worker to locate community resources for complementary therapy 4. Unlicensed assistive personnel to help client with a warm shower in the morning 5. Family members are encouraging the client to “tough out the pain” rather than risk drug addiction to opioids. The client is stoically abiding. The nurse recognizes that the sociocultural dimension of pain is the current priority for the client. Which question will the nurse ask? 1. “Where is the pain located, and does it radiate to other parts of your body?” 2. “How would you describe the pain, and how is it affecting you?” 3. “What do you believe about pain medication and drug addiction?” 4. “How is the pain affecting your activity level and your ability to function?” 6. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will the nurse advocate for first? 1. Gabapentin 2. Corticosteroids 3. Hydromorphone 4. Lorazepam 7. Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia 8. The nurse is caring for a postoperative client who reports pain. Based on recent evidence-based guidelines, which approach would be best? 1. Multimodal strategies 2. Standing orders by protocol 3. Intravenous patient-controlled analgesia (PCA) 4. Opioid dosage based on valid numerical scale 9. The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical 47 measures. What action should the charge nurse take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for documenting dose and time and discuss documentation deficits. 10. Which clients must be assigned to an experienced RN? Select all that apply. 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis 11. In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. Client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed. 12. The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern? 1. A 35-year-old opioid-naïve adult will receive a basal dose of morphine via IV patient-controlled analgesia (PCA). 2. A 65-year-old adult will be discharged with a prescription for nonsteroidal anti-inflammatory drugs (NSAIDS). 3. A 25-year-old adult is prescribed as needed intramuscular (IM) analgesic for pain. 4. A 45-year-old adult is taking oral fluids and foods has orders for IV morphine. 13. Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp chest pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an elevated blood pressure 14. When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 48 2. Titrate upward until the client is pain free or acceptable level is reached. 3. Titrate downward to prevent toxicity, overdose, and adverse effects. 4. Titrate to a dosage that is adequate to meet the client's subjective needs. 15. The health care provider prescribes 7 mg morphine IV as needed (PRN). The nursing student prepares the medication and shows the syringe (see figures below) to the nursing instructor. What should the nursing instructor do first? 49 50 1. Tell the student to review the provider's prescription before administering medication. 2. Waste the medication and tell the student that remediation is required for serious error. 3. Ask the student to demonstrate the calculations and steps required to prepare the dose. 4. Accompany the student to the client's room and observe as the medication is administered. 16. A client received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that the client has a respiratory rate of 10 breaths/min. What is the priority action? 1. Call the health care provider to obtain an order for naloxone. 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20 breaths/min. 4. Double-check the prescription to see which drugs were ordered. 17. The client is diagnosed by the emergency department health care provider (HCP) with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed? 1. The HCP is considering dexamethasone to prevent reoccurrence, and the client has type 2 diabetes. 2. The HCP is considering subcutaneous sumatriptan, and the client took ergotamine 3 hours ago. 3. The HCP is considering metoclopramide, and this is a first-time migraine for the client. 4. The HCP is considering prochlorperazine, and the client drove himself to the hospital. 18. Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Older adult client with chronic pain related to joint immobility 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Opioid-naïve adolescent with an arm fracture and cystic fibrosis 19. A client is crying and grimacing but denies pain and refuses pain medication because “my brother is a drug addict and has ruined our lives.” What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 51 4. Seek family assistance in resolving this problem. 20. A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps 21. In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress 22. The health care provider (HCP) has ordered a placebo for a client with chronic pain. The newly hired nurse feels very uncomfortable administering the medication. What is the first action that the new nurse should take? 1. Prepare the medication and hand it to the HCP. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice and suggestions. 23. For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Note the time of and client's response to the last dose of analgesic. 4. Give the maximum as needed (PRN) dose within the minimum time frame for relief. 24. The oncoming day shift nurse has received the shift report from the night nurse. The day shift nurse has done a quick check on all of the clients and has determined that all are stable and not in acute distress. Prioritize the order in which the oncoming nurse will care for the following clients, 1 being the first and 5 being the last. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Older man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is 52 scheduled for diagnostic testing this morning. 4. Older woman with advanced Alzheimer disease who requires total care for all activities of daily living. She struggles during any type of nursing care, and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued. _____, _____, _____, _____, _____ 25. On the first day after surgery, a client receiving an analgesic via patient- controlled analgesia pump reports that the pain control is inadequate. What is the first action that the nurse should take? 1. Deliver the bolus dose per standing order. 2. Contact the health care provider (HCP) to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity. 26. The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered 27. What is the best way to schedule medication for a client with constant pain? 1. As needed (PRN) at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around-the-clock 28. Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump 2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications 53 29. The nurse is caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells the nurse that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3°F (37.9°C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. The nurse decides to notify the client's provider. Place the following report information in the correct order according to the SBAR (situation, background, assessment, recommendation) format. 1. “He is restless and anxious: temperature is 100.3°F (37.9°C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds.” 2. “He had abdominal surgery yesterday. He is on morphine via patient- controlled analgesia, but he says the pain is getting progressively worse.” 3. “I have tried to make him comfortable, and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation.” 4. “Would you like to give me an order for any laboratory tests or additional therapies at this time?” 5. “Dr. S, this is Nurse J from Unit X. I’m calling about Mr. D, who is reporting severe abdominal pain.” _____, _____, _____, _____, _____ 30. Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication 31. A client's family member comes to the nurse's station and says, “He needs more pain medicine. He is still having a lot of pain.” What is the nurse's best response? 1. “The health care provider (HCP) ordered the medicine to be given every 4 hours.” 2. “If medication is given too frequently, there are ill effects.” 3. “Please tell him that I will be right there to check on him.” 54 4. “Let's wait about 40 minutes. If there he still hurts, I’ll call the HCP.” 32. Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, “None of these doctors has done anything to help.” Which client statement is cause for greatest concern? 1. “I twisted my back last night, and now the pain is a lot worse.” 2. “I’m so sick of this pain. I think I’m going to find a way to end it.” 3. “Occasionally, I buy pain killers from a guy in my neighborhood.” 4. “I’m going to sue you and the doctor; you aren’t doing anything for me.” 33. A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced unlicensed assistive personnel (UAP) states that she received training in indwelling catheter insertion at a previous job. What task can be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is inserted and obtaining a specimen 34. The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The client begs, “Please don’t stop the morphine. My pain is really a lot worse today than it was yesterday.” What is the best response? 1. “Let me stop the pump, and we can try oral pain medication to see if it relieves the pain.” 2. “I realize that you are scared of the pain, but we must try to wean you off the pump.” 3. “Show me where your pain is and describe how it feels compared with yesterday.” 4. “Let's take your vital signs; then I will discuss your concerns with the health care provider.” 35. The nurse is caring for a young client with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action? 1. Notify the charge nurse and make arrangements to transfer to intensive care. 2. Explain significance of BG and insulin and then call the health care 55 provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin. 36. The nurse is working with a health care provider who prescribes opioid doses based on a specific pain intensity rating (dosing to the numbers). Which client circumstance is cause for greatest concern? 1. A 73-year-old frail female client with a history of chronic obstructive pulmonary disease is prescribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10. 2. A 25-year-old postoperative male client with a history of opioid addiction is prescribed one tablet of oxycodone and acetaminophen for pain of 4 to 5 on a scale of 0 to 10. 3. A 33-year-old opioid-naïve female client who has a severe migraine headache is prescribed 5 mg IV morphine for pain of 7 to 8 on a scale of 0 to 10. 4. A 60-year-old male with a history of rheumatoid arthritis is prescribed one tablet of hydromorphone for pain of 5 to 6 on scale of 0 to 10. 37. The nurse recognizes that there are ethical considerations in helping clients to achieve relief from pain. Which nursing action is the best example of the principle of nonmaleficence? 1. Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. 2. Client has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine. 3. Client is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the client to verbalize personal goals for pain management. 4. Client repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication. 38. The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction? 1. Client reports shortness of breath. 2. Client is more difficult to arouse. 3. Client is more anxious and nervous. 4. Client reports pain is worsening. 39. The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain? 56 1. Nurse A uses a behavioral assessment tool when the client is engaged in activities. 2. Nurse B asks a client who doesn’t speak English to point to the location of pain. 3. Nurse C uses the same numerical rating scale every day for the same client. 4. Nurse D asks the daughter of a confused client to describe the client's pain. 40. For which of these clients is IV morphine the first-line choice for pain management? 1. A 33-year-old intrapartum client needs pain relief for labor contractions. 2. A 24-year-old client reports severe headache related to being hit in the head. 3. A 56-year-old client reports breakthrough bone pain related to multiple myeloma. 4. A 73-year-old client reports chronic pain associated with hip replacement surgery. 41. The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction? 1. Frequently likes to sit in the hot tub to reduce joint stiffness 2. Prefers to place the patch only on the upper anterior chest wall 3. Saves and reuses the old patches when he can’t afford new ones 4. Changes the patch every 4 days rather than the prescribed 72 hours 42. The home health nurse discovers that an older adult client has been sharing his pain medication with his daughter. Despite the nurse's warnings about the dangers of sharing, he states, “My daughter can’t afford to see a doctor or to buy medicine, so I must give her a few of my pain pills.” Which member of the health care team is the nurse most likely to consult first? 1. Health care provider to renew the prescription so that client has enough medicine 2. Pharmacist to monitor the frequency of the prescription refills 3. Social worker to help the family locate resources for health care 4. Home health aide to watch for inappropriate medication usage by family 43. For a postoperative client, the health care provider (HCP) prescribed multimodal therapy, which includes acetaminophen, nonsteroidal anti- inflammatory drugs, as needed (PRN) opioids, and nonpharmaceutical interventions. The client continuously asks for the PRN opioid, and the nurse suspects that the client may have a drug abuse problem. Which action by the nurse is best? 1. Administer acetaminophen and spend extra time with the client. 2. Explain that opioid medication is reserved for moderate to severe pain. 3. Give the opioid because client deserves relief and drug abuse is 57 unconfirmed. 4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription. 44. An inexperienced graduate nurse is reviewing the medication administration record (MAR) for a client who has a patient-controlled analgesia (PCA) pump for pain management. The new nurse compares the MAR and the health care provider's (HCP’s) prescription, and both indicate that larger doses are prescribed at night compared with doses throughout the day. Which member of the health care team should the new nurse consult first? 1. Ask the client if he typically needs extra medication in the evening. 2. Ask the HCP to verify that the larger amount is the correct dose. 3. Ask the pharmacist to confirm the dosage on the original prescription. 4. Ask the charge nurse if this is a typical dosage for nighttime PCA. 58 Answer Key 1. Ans: 2 Inadequate pain management for postsurgical clients can affect quality of life, function, recovery, and postsurgical complication; thus, all the manifestations are examples of negative results. However, venous thromboembolism can lead to pulmonary embolism, and this is an immediate life-threatening concern. The nurse also needs to implement interventions to resolve unsatisfied needs, fear of pain, and hopelessness related to pain and function. Focus: Prioritization; Test Taking Tip: Use Maslow's hierarchy to identify priorities in caring for clients. Physiologic needs are the first concern. In this case, venous thromboembolism is the most serious physiologic outcome secondary to inadequate pain management. 2. Ans: 4 The charge nurse must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, Prioritization; Test Taking Tip: The first step of nursing process is assessment. In this case, the charge nurse applies nursing process to assess the nursing staff's performance and attitudes. 3. Ans: 1, 2, 3, 4 The American Pain Society in collaboration with the American Society of Anesthesiologists recommendations for postoperative clients include: acetaminophen and/or NSAIDs if there are no contraindications; surgical site-specific peripheral regional anesthetic for procedures; neuraxial analgesia (also known as epidural) for major thoracic and abdominal procedures, if client has risk for cardiac complications or prolonged ileus; and multimodal therapy, which includes use of different types of medications and other therapies. Long-acting oral opioids are not recommended in the postoperative period. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine is not recommended. Focus: Prioritization; Test Taking Tip: Passing a test and working as a competent nurse requires keeping up to date with current practice guidelines. Select all that apply questions are particularly challenging. Read each option carefully and try to exclude incorrect options. 4. Ans: 4 One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions. Focus: Delegation. 5. Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. 59 Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization. 6. Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be prescribed as an adjuvant medication. Focus: Prioritization. 7. Ans: 3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine. Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization. 8. Ans: 1 Multimodal therapies for postoperative clients include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies. This approach is thought to be the most important strategy for pain management for most postoperative clients. Standing orders are less optimal because there is no consideration of individual needs or characteristics. PCA is one important element, but not all clients can manage PCA devices. Assessment tools are an important part of overall management, but basing opioid dose on a numerical scale does not consider individual client circumstances. Focus: Prioritization. 9. Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision. 10. Ans: 1, 3, 5, 6 These clients should be assigned to an experienced RN because all have acute conditions that require close monitoring for any developing complications. Abdominal cramps secondary to food poisoning is an acute condition; however, the cramping, vomiting and diarrhea are usually self- limiting. The client with chronic back pain would be considered physically stable. Although all clients will benefit from care provided by an experienced RN, the client with abdominal cramps and the client with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse. Focus: Assignment; Test Taking Tip: To determine acuity of clients, use nursing concepts, such as gas exchange and perfusion. Clients 1, 3, 5, and 6 could have potential problems related to perfusion. The client with the chest tube could also have a potential problem related to gas exchange. 11. Ans: 3 The client must be believed, and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to the other options in developing the treatment plan. Focus: Prioritization. 60 12. Ans: 1 The nurse would consider questioning all of the medication prescriptions, but the opioid-naïve adult has the greatest immediate risk, because use of a basal dose has been associated with an increased incidence of respiratory depression in opioid-naïve clients. Older adults are frequently prescribed NSAIDS; however, they are used with caution, and the client's history should be reviewed for potential problems, such as a history of gastrointestinal bleeding, cardiac disease, or renal dysfunction. Many medications such as anticoagulants, oral hypoglycemics, diuretics, and antihypertensives can also cause adverse drug–drug interactions with NSAIDs. IM injections cause pain, absorption is unreliable, and there are no advantages over other routes of administration routes. If a client is able to tolerate oral foods and fluids, oral medications are preferred because the efficacy of the oral route is equal to the IV route. Focus: Prioritization; Test Taking Tip: It is worthwhile to study the purposes, pharmacologic actions, and side effects of commonly used medications. Morphine is considered the prototype of the opioid medications. For opioid-naïve clients, the priority concern is respiratory depression. For clients who need opioids for long-term pain management, the primary side effect is constipation. 13. Ans: 3 The client with an acute myocardial infarction has the greatest need for IV access and is likely to receive morphine, which will relieve pain and increase venous capacitance. The other clients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent. Focus: Prioritization. 14. Ans: 1 The goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Focus: Prioritization. 15. Ans: 3 . The student has made an error and the syringe, as shown, contains 70 mg. The syringe contains 7 mL of medication. The student should have obtained a tuberculin syringe and drawn up 0.7 mL. First, the nursing instructor would assess the student's knowledge and understanding of the calculations and method of preparing the medication. The instructor would use this approach to help the student self-identify errors, which might include misinterpreting the original prescription, misreading the label, or misreading the syringe markings. Focus: Prioritization, Supervision. 16. Ans: 2 The UAP has correctly reported findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on assessment findings, the other options may also be appropriate. Focus: Prioritization. 17. Ans: 2 The American Headache Society developed recent guidelines for treatment of acute migraines. Intravenous metoclopramide and prochlorperazine and subcutaneous sumatriptan are recommended for adults 61 who present with first-time onset of acute migraines. Sumatriptan should not be used if ergotamine, dihydroergotamine, or other triptan medication has been used in the past 24 hours because of the additive effect of narrowing of the blood vessels that could result in damage to major organs (e.g., stroke or myocardial infarction). Dexamethasone may cause increased glucose levels. Prochlorperazine can cause drowsiness. Focus: Prioritization. 18. Ans: 4 At greatest risk are older adult clients, opiate-naïve clients, and those with underlying pulmonary disease. The adolescent has two of the three risk factors. Focus: Prioritization. 19. Ans: 1 This client has strong beliefs and emotions related to the issue of the brother's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, and their beliefs about drug addiction may be similar to those of the client. Focus: Prioritization. 20. Ans: 3 Diaphoresis is one of the early signs that occurs between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal. Focus: Prioritization; Test Taking Tip: In studying for NCLEX®, pay attention to early signs of disease processes. Early detection is considered a safety measure; therefore, NCLEX® tests to determine if you can perform early identification of potential problems. 21. Ans: 1 The UAP can assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities. Focus: Delegation. 22. Ans: 4 Administering placebos is generally considered unethical. (There are circumstances, such as clinical drug research where placebos are used, but clients are aware of that possibility.) The charge nurse is a resource person who can help clarify the situation and locate and review the hospital policy. If the HCP is insistent, suggest that he or she could give the placebo. (Note: Use “could,” not “should,” when talking to the HCP. This provides a small opportunity to rethink the decision. “Should” elicits a more defensive response.) Although following a personal ethical code is correct, the nurse must ensure that the client is not abandoned and that care continues. Focus: Prioritization. 23. Ans: 2 Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff must rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns. Focus: Prioritization. 24. Ans: 5, 3, 1, 2, 4 All of the clients are in relatively stable condition. The client with the pneumothorax has priority because chest tubes can leak or become 62 dislodged or blocked. Lung sounds and respiratory effort should be evaluated before and after removal of the chest tube. The woman who will be leaving the unit for diagnostic testing should be assessed and prepared, as needed, before she leaves for the procedure. In a client with meningitis, a headache is not unexpected, but neurologic status and pain should be assessed. The report of postoperative pain is expected, but this client is getting reasonable relief most of the time. Caring for and assessing the client with Alzheimer disease is likely to be very time consuming; caring for her last prevents delaying care for all the others. In addition, elderly clients with dementia benefit if the caregiver does not act rushed or hurried. Focus: Prioritization. 25. Ans: 4 Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps. Focus: Prioritization; Test Taking Tip: During clinical rotations, you may observe nurses giving pain medication without performing an adequate pain assessment. This is an error in clinical performance. In postoperative clients, pain could signal complications, such hemorrhage, infection, or decreased perfusion related to tissue swelling. Always assess pain first; then make a decision about giving medication, using nonpharmacologic methods, or contacting the HCP. 26. Ans: 4 The LPN/LVN is well trained to administer oxygen per nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy. Focus: Assignment. 27. Ans: 4 If the pain is constant, the best schedule is around-the-clock to provide steady analgesia and pain control. The other options may require higher dosages to achieve control. Focus: Prioritization. 28. Ans: 2, 3, 6 The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma. Focus: Assignment. 29. Ans: 5, 2, 1, 3, 4 Using the SBAR format, the nurse first identifies himself or herself, gives the client's name, and describes the current situation. Next, relevant background information, such as the client's diagnosis, medications, and laboratory data, is stated. The assessment includes both client assessment data that are of concern and the nurse's analysis of the situation. Finally, the nurse makes a recommendation indicating what action he or she thinks is needed. Focus: Prioritization. 63 30. Ans: 2, 5, 6 The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with acquired immune deficiency syndrome has complex issues that require expert assessment skills. The client pending discharge will need special and detailed instructions. Focus: Assignment. 31. Ans: 3 Responding to the client and family in a timely fashion is important. Next, directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next. Focus: Prioritization. 32. Ans: 2 This statement is a veiled suicide threat, and clients with pain disorder and depression have a high risk for suicide. New injuries must be evaluated, but this type of pain report is not uncommon for clients with pain disorder. Risk for substance abuse is very high and should eventually be addressed. The client can always threaten to sue, but the nurse must remain calm and continue to provide care with professional courtesy. Focus: Prioritization. 33. Ans: 4 Measuring output and obtaining a specimen are within the scope of practice of the UAP. Insertion of the indwelling catheter in this client should be done by an experienced RN because clients with obstruction and retention are usually very difficult to catheterize, and the nurse must evaluate the pain response during the procedure. The UAP's knowledge of sterile technique or catheter insertion is not the issue. Focus: Delegation. 34. Ans: 3 Assessing the pain is the priority in this acute care setting because there is a risk of infection or hemorrhage. The other options might be appropriate based on the assessment findings. Focus: Prioritization. 35. Ans: 2 Explain that insulin is a priority because life-threatening ketoacidosis may already be in progress. If she is already aware of the dangers of an elevated BG level, then her refusal suggests ongoing suicidal intent and the provider should be notified so that steps can be taken to override her refusal (potentially a court order). A BG level of over 600 mg/dL (33.3 mmol/L) is typically a criterion for transfer to intensive care, but making arrangements for transfer is time consuming, and treatment of the elevated BG should begin as soon as possible. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of elevated BG and possible ongoing suicidal intent. Focus: Prioritization. 36. Ans: 1 According to the American Society for Pain Management Nursing, prescribing opioid medication based solely on pain intensity should be prohibited because there are many other factors to consider (e.g., age, health conditions, medication history, respiratory status). Age, small body mass, and underlying respiratory disease put the 73-year-old client at greatest risk 64 for overmedication and respiratory depression. Clients with history of opioid addiction will have a different response to medication and may need higher doses to achieve relief. IV morphine may actually worsen migraine headaches, and other first-line drugs (metoclopramide and prochlorperazine and subcutaneous sumatriptan) are more effective. Hydromorphone is not typically prescribed for the pain associated with chronic of rheumatoid arthritis. Focus: Prioritization. 37. Ans: 1 Nonmaleficence is to prevent harm. If the client is excessively sedated, the nurse knows that giving additional opioid medication could do more harm than good, so the nurse would conduct further assessments and seek alternative options for pain relief. The client's report of pain should be believed, so based on the principle of justice, the nurse advocates for pain medication even though an organic cause of disease is not identified. By encouraging the client to have a voice in her or his own pain management goals, the nurse is applying the principle of autonomy. By explaining the benefits of pain medication, the nurse is applying the principle of beneficence to help the client recognize the balance between pain control and safety. Focus: Prioritization. 38. Ans: 2 Most adverse opioid events are preceded by an increased level of sedation. Focus: Prioritization. 39. Ans: 3 Pain assessment is very complex, but the consistent use of the same assessment tool is the best method. The nurse should use all tools in conjunction with observation, clients’ self-report, and other assessment skills. When a client is engaged in an activity, behavior may not accurately reflect pain. Asking a client to point to the pain is only one part of the total pain assessment. Relatives of confused clients can assist the nurse to recognize the meaning of behaviors, but they are not able to describe pain sensations for the client. Focus: Supervision. 40. Ans: 3 The client with cancer needs morphine for symptom relief. For obstetric clients, morphine can suppress fetal respiration and uterine contractions, so regional or epidural methods are preferred. For head injuries, morphine could make evaluation of mental status more difficult. In addition, if respirations are depressed, intracranial pressure could increase. Opioids are usually not the first-line choice for chronic pain, and opioids must be used with caution in older adult clients because of changes related to aging, such as renal clearance. In addition, use of opioids increases risk for falls and contributes to constipation. Focus: Prioritization. 41. Ans: 1 All of these behaviors require correction; however, heat can increase the release of medication from the patch and result in a sudden overdose. The client should be urged to rotate sites to prevent irritation of the skin. Reusing old patches and delaying the patch changes are likely to give less than optimal pain relief. Based on assessment of behaviors, the nurse would reeducate about use of the patch, help the client seek financial resources, or develop a reminder system for patch change intervals. Focus: Prioritization. 65 42. Ans: 3 If the social worker can assist the family to find affordable alternatives, then the father is more likely to stop giving his medication to the daughter. Focus: Prioritization. 43. Ans: 3 The nurse is weighing benefit against harm. If client is a drug abuser, the medication given in the hospital is not harming him. If the client is not a drug abuser, then withholding the medication causes him to suffer pain because of unconfirmed suspicions. The nurse must also remember that medical use of opioids does not cause addiction and for clients who are addicted, withholding medication in the hospital setting does not resolve the addictive behavior. Focus: Prioritization. 44. Ans: 4 The nurse has taken the first correct step and compared the MAR to the HCP's original prescription. Because the nurse is new, the charge nurse would be the best resource. In fact, larger PCA doses are given at night to increase the interval between doses. This helps the client to rest and sleep. The nurse can contact the other members of the health care team at any time if the charge nurse is unable to help. Focus: Prioritization. 66 CHAPTER 2 67 Cancer 68 Questions 1. The patient describes a burning sensation in the leg. The health care provider tells the nurse that a medication will be prescribed for neuropathic pain secondary to chemotherapy. The nurse is most likely to question the prescription of which drug? 1. Imipramine 2. Carbamazepine 3. Gabapentin 4. Morphine 2. A patient who has cancer will need ongoing treatment for pain. Which brochure is the nurse most likely to prepare that addresses questions related to the first-line treatment of cancer pain? 1. “An Illustrated Guide to the Analgesic Ladder” 2. “Common Questions About Radiation Therapy” 3. “How to Make Preparations for Your Cancer Surgery” 4. “How Nerve Blocks Can Help to Manage Cancer Pain” 3. Which nurse is demonstrating the first step in managing cancer pain by using the ABCDE (ask, believe, choose, deliver, and empower) clinical approach to pain management as recommended by the Agency for Healthcare Research and Quality? 1. Nurse J asks if the time of the prescribed dose of medication can be changed. 2. Nurse K asks the patient to describe pain and uses a numerical pain scale. 3. Nurse L asks the patient to participate and to contribute in pain management. 4. Nurse M asks about pain management options that are appropriate for the patient. 4. The nurse assesses the patient and determines that the patient is having frequent breakthrough cancer pain. Which member of the health care team is the nurse most likely to contact first? 1. Physical therapist to reevaluate physical therapy routines 2. Health care provider to review medication, dosage, and frequency 3. Unlicensed assistive personnel to provide more assistance with activities of daily living 4. Psychiatric clinical nurse specialist to evaluate psychogenic pain 5. The night shift nurse tells the oncoming dayshift nurse that the cancer patient is on around-the-clock dosing of morphine but that the patient might be having end-of-dose pain. Which question is the most important to ask the 69 night shift nurse? 1. “How many times did you have to give a bolus dose of morphine?” 2. “Did the patient tell you that the pain was greater than a 5/10?” 3. “Did you notify the health care provider (HCP), and were changes prescribed?” 4. “Did you try any nonpharmaceutical therapies or adjuvant medications? 6. The nurse is caring for a patient with esophageal cancer. Which task could be delegated to unlicensed assistive personnel (UAP)? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weights 7. A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While the nurse is trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority nursing concept to consider in responding to this patient? 1. Elimination 2. Patient education 3. Cellular regulation 4. Anxiety 8. Which patient is at greatest risk for pancreatic cancer? 1. An older African-American man who smokes 2. A young white obese woman with gallbladder disease 3. A young African-American man with type 1 diabetes 4. An elderly white woman who has pancreatitis 9. Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? Select all that apply. 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs. 10. When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/LVN under the supervision of a team leader RN? 70 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy 11. A community health center is preparing a presentation on the prevention and detection of cancer. Which task would be best to assign to the LPN/LVN? 1. Explain screening examinations and diagnostic testing for common cancers. 2. Discuss how to plan a balanced diet and reduce fats and preservatives. 3. Prepare a poster on the seven warning signs of cancer. 4. Describe strategies for reducing risk factors such as smoking and obesity. 12. The health care provider (HCP) tells the patient with cancer that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. Which patient statement is cause for greatest concern? 1. “My symptoms will eventually be cured; I’m so happy that I don’t have to worry any longer.” 2. “My doctor is trying to help me control the symptoms; I am grateful for the extension of time with my family.” 3. “My pain will be relieved, but I am going to die soon; I would like to have control over my own life and death.” 4. “Initially, I may have to take some time off work for my treatments; I can probably work full time in the future.” 13. For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment 14. An older patient needs treatment and relief for severe localized pain related to postherpetic neuralgia that developed during chemotherapy. The nurse is most likely to question the prescription of which type of medication? 1. Lidocaine patch 2. Gabapentinoid 3. Capsaicin patch 4. Tricyclic antidepressant 15. For a patient receiving the chemotherapeutic drug vincristine, which side effect should be reported to the health care provider (HCP)? 1. Fatigue 71 2. Nausea 3. Paresthesia 4. Anorexia 16. An experienced nurse is precepting a newly hired nurse who has 2 years of medical-surgical experience but limited experience with patients who have cancer. The new hire seems to be consistently under medicating the patients’ pain. What should the preceptor do first? 1. Reassess all of the patients and administer additional pain medication as needed. 2. Write an incident report and inform the nurse manager about the nurse's performance. 3. Determine the new nurse's understanding and beliefs about cancer pain and treatments. 4. Ask the new nurse about past experience in administering pain medications. 17. For a patient who is receiving chemotherapy, which laboratory result is of particular importance? 1. White blood cell count 2. Prothrombin time 3. Electrolyte levels 4. Blood urea nitrogen level 18. For care of a patient who has oral cancer, which task would be appropriate to assign to an LPN/LVN? 1. Assisting the patient to perform oral hygiene 2. Explaining when brushing and flossing are contraindicated 3. Giving antacids and sucralfate suspension as ordered 4. Recommending saliva substitutes 19. When staff assignments are made for the care of patients who are receiving chemotherapy, what is the major consideration regarding chemotherapeutic drugs? 1. Administration of chemotherapy requires precautions to protect self and others. 2. Many chemotherapeutic drugs are vesicants. 3. Chemotherapeutic drugs are frequently given through central venous access devices. 4. Oral and venous routes of administration are the most common. 20. The oncoming day shift nurse has just received hand over report from the night shift nurse. List the order of priority for assessing and caring for the following patients, with 1 being first and 4 being last. 1. A patient who developed tumor lysis syndrome around 5:00 am 72 2. A patient who is currently pain free but had breakthrough pain during the night 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory nausea and vomiting for the past 24 hours _______, _______, _______, _______ 21. The nurse is monitoring a patient who is at risk for spinal cord compression related to tumor growth. Which patient statement is most likely to suggest an early manifestation? 1. “Last night my back really hurt, and I had trouble sleeping.” 2. “My leg has been giving out when I try to stand.” 3. “My bowels are just not moving like they usually do.” 4. “When I try to pass urine, I have difficulty starting the stream.” 22. The nurse is caring for an older woman with hepatic cancer. Unlicensed assistive personnel informs the nurse that the patient's level of consciousness is diminished compared with earlier in the shift. Prioritize the steps of assessment and intervention related to this patient's change of mental status. 1. Take vital signs, including pulse, respirations, blood pressure, and temperature. 2. Check responsiveness and level of consciousness. 3. Obtain a blood glucose reading; give glucose per protocol. 4. Check electrolyte values. 5. Check ammonia level. 6. Check pulse oximeter readings and administer oxygen as needed. _______, _______, _______, _______, _______, _______ 23. The day shift nurse is assessing the patient who has breast cancer and notices edema of the face, periorbital edema, and tightness around the neck of the gown. The nurse immediately notifies the health care provider for early signs and symptoms of superior vena cava syndrome. On the figure below identify the superior vena cava.