The nurse is completing an assessment on a nonverbal adult patient. Which type of pain scale
assessment tool is the most accurate to use?
a. TPPPS
b. FLACC
c. POCIS
d. MOPS - correct answersANS: B
The Face, Legs, Activity, Cry, Consolability (FLACC) scale would be used to assess pain in
the nonverbal patient. The Toddler Preschooler Postoperative Pain Scale (TPPPS), Pain
Observation Scale for Young Children (POCIS), and Modified Objective Pain Scale (MOPS)
would not be appropriate for this patient.
Which action will the nurse take when a patient receiving morphine sulfate via percutaneous
coronary angioplasty (PCA) has a shallow, irregular respiratory rate of 6 breaths/min?
a. Elevate the patient's head of bed to facilitate lung expansion.
b. Increase the patient's primary intravenous (IV) flow rate.
c. Complete the FLACC scale.
d. Notify the health care provider and prepare to administer naloxone (Narcan). - correct answersANS: D
The patient is exhibiting signs of respiratory depression. Administration of the antidote
naloxone would be the most appropriate nursing intervention. Lung expansion or increasing
the primary IV infusion rate would not relieve respiratory depression. Assessing the patient's
pain at this point is a lesser priority than treating the respiratory depression.
Which patient assessment would indicate to the nurse that salicylate toxicity is occurring?
a. Gastrointestinal (GI) bleeding
b. Increased bleeding times
c. Tinnitus
d. Occasional nausea - correct answersANS: C
Symptoms of salicylism include ringing in the ears (tinnitus), impaired hearing, dimming of
, vision, sweating, fever, lethargy, dizziness, mental confusion, nausea, and vomiting. Although
salicylates may cause GI bleeding over time, it is not a symptom associated with toxicity.
What is the advantage of taking a nonsteroidal anti inflammatory drug (NSAID) that is a COX
2 inhibitor?
a. The medication is cheaper than aspirin.
b. There are fewer GI adverse effects.
c. They are more effective than COX 1 inhibitors.
d. They have no known adverse effects. - correct answersANS: B
COX 2 inhibitor NSAIDs have fewer GI adverse effects than salicylates or COX 1 inhibitors.
Aspirin is one of the least expensive analgesics available. The anti inflammatory actions of
NSAIDs are caused by COX 2 inhibition; the unwanted adverse effects are caused by
inhibition of COX 1. All these medications have adverse effects.
An 86 year old patient who was admitted with GI bleeding as a result of salicylate therapy is
being discharged. As the nurse reviews the discharge medication list, the patient states that
she doesn't understand why Tylenol doesn't work as well as the aspirin she had been taking.
What would be the nurse's best response?
a. "Tylenol and aspirin are chemically the same drug."
b. "Tylenol is appropriate for only minor pain."
c. "Tylenol does not help with inflammatory discomfort."
d. "A therapeutic blood level must be established with Tylenol." - correct answersANS: C
Acetaminophen (Tylenol) is effective as an analgesic or antipyretic. Tylenol does not possess
any anti inflammatory activity and is therefore ineffective in relieving symptoms related to
inflammation. Tylenol and aspirin are distinctly different drugs. Tylenol can be useful in the
relief of moderate pain. Tylenol can be effective in a single dose, without needing treatment
over a period of time.
What term is used to define an awareness of pain?