546 Exam 1 Practice Questions And
Answers With Verified Solutions (Graded
A+)
Which of the following is NOT a likely sign of pain in a patient who cannot verbally
communicate with you?
a.Eyes clenched shut when turning the patient
b.Decreased respiratory rate
c.Patient resists bending of her elbow when you try to contract her arm
d.Heart rate of 120 in a 54 year old male - ANSWER B. a decreased respiratory
rate is not commonly associated with pain. This could actually be due to too much
opioid analgesia depressing the patient's respiratory system
B. RAAS......................................................................................................................5
C. CPOT......................................................................................................................5
•Grimacing
•Restlessness
•Ventilator asynchrony
• Tense muscles resistant to passive motion.
What would you assess his pain as utilizing the Critical-Care Pain Observation Tool
(CPOT)?
D.8 - ANSWER C: score of 7
2 for facial expressions
, 2 for body movements
2 for ventilator compliance
1 for muscle tension
You walk into your intubated patient's room with an IV fentanyl drip at
25mcg/hour who presents with the following:
Heart rate: 130
BP: 140/90
RR: 29
Which of the following should the nurse do first?
1.Ask the patient to rank her pain on a scale of 0-10
2.Increase the fentanyl drip rate per protocol
3.Call the physician for additional pain medication orders
4.Get a music therapy consult
5.Look at the patient's facial expression and muscle tension - ANSWER Correct
answer: 5 (assess first)
You walk into your intubated patient's room with an IV fentanyl drip at
25mcg/hour who presents with the following:
Heart rate: 130
BP: 140/90
RR: 29, ventilator alarming
Hands clenched, brow narrowed, patient eyes open and looking at you anxiously.
Which of the following should the nurse do first?
Answers With Verified Solutions (Graded
A+)
Which of the following is NOT a likely sign of pain in a patient who cannot verbally
communicate with you?
a.Eyes clenched shut when turning the patient
b.Decreased respiratory rate
c.Patient resists bending of her elbow when you try to contract her arm
d.Heart rate of 120 in a 54 year old male - ANSWER B. a decreased respiratory
rate is not commonly associated with pain. This could actually be due to too much
opioid analgesia depressing the patient's respiratory system
B. RAAS......................................................................................................................5
C. CPOT......................................................................................................................5
•Grimacing
•Restlessness
•Ventilator asynchrony
• Tense muscles resistant to passive motion.
What would you assess his pain as utilizing the Critical-Care Pain Observation Tool
(CPOT)?
D.8 - ANSWER C: score of 7
2 for facial expressions
, 2 for body movements
2 for ventilator compliance
1 for muscle tension
You walk into your intubated patient's room with an IV fentanyl drip at
25mcg/hour who presents with the following:
Heart rate: 130
BP: 140/90
RR: 29
Which of the following should the nurse do first?
1.Ask the patient to rank her pain on a scale of 0-10
2.Increase the fentanyl drip rate per protocol
3.Call the physician for additional pain medication orders
4.Get a music therapy consult
5.Look at the patient's facial expression and muscle tension - ANSWER Correct
answer: 5 (assess first)
You walk into your intubated patient's room with an IV fentanyl drip at
25mcg/hour who presents with the following:
Heart rate: 130
BP: 140/90
RR: 29, ventilator alarming
Hands clenched, brow narrowed, patient eyes open and looking at you anxiously.
Which of the following should the nurse do first?
