HESI PN COMPREHENSIVE EXIT EXAM

HESI PN COMPREHENSIVE EXIT EXAM 1. The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to be premedicated before walking b. The patient who has a PCA running that needs the syringe replaced The patient who needs to take a scheduled dose of maintenance pain c. medication The patient who is experiencing 8/10 pain and has an immediate order for pain medication ANS: D Immediate (STAT) medications need to be given as soon as possible. In addition, this patient is the priority because of the report of severe pain. The other patients need pain medication, but their situations are not as high a priority as that of the patient with the STAT medication order. 2. The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse’s assessment? a. The patient needed a substantial dose of naloxone (Narcan). b. The patient needs increasingly higher doses of opioid to control pain. The patient no longer experiences sedation from the usual dose of c. opioid. The patient asks for pain medication close to the time it is due around the clock. ANS: B Opioid tolerance occurs when a patient needs higher doses of an opioid to control pain. Naloxone (Narcan) is an opioid antagonist that is given to reverse the effects of opioid overdose. Taking pain medications regularly around the clock is an effective way to control pain. The pain medication for this patient is most likely effectively managing the patient’s pain because the patient is not asking for the medication before it is due. A patient no longer experiencing a side effect (sedation) of an opioid does not indicate opioid tolerance. 29.A nurse is caring for a patient with rheumatoid arthritis who is now going to 1 d. d. ` be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient’s social history is the nurse most concerned about? a. Patient drinks 1 to 2 glasses of wine every night. b. Patient smokes 2 packs of cigarettes a day. c. Patient occasionally uses marijuana. d. Patient takes antianxiety medications. ANS: A The major adverse effect of acetaminophen is hepatotoxicity (liver toxicity). Because both alcohol and acetaminophen are metabolized by the liver, when taken together, they can cause liver damage. Smoking cigarettes and smoking marijuana are not healthy behaviors, but their effects on health are not affected by acetaminophen. Antianxiety medications can be taken with acetaminophen. 30. The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse’s first priority? a. Call the rapid response team. b. Start an intravenous (IV) line. c. Administer pain-relief medications. d. Ask the patient to rate and describe the pain. ANS: D The nurse’s ability to establish a nursing diagnosis, plan and implement care, and evaluate the effectiveness of care depends on an accurate and timely assessment. The other responses are all interventions; the nurse cannot know which intervention is appropriate until the nurse completes the assessment. 31. The nurse is caring for a group of patients. Which task may the nurse delegate to the nursing assistive personnel (NAP)? a. Administer a back massage to a patient with pain. b. Assessment of pain for a patient reporting abdominal pain. c. Administer patient-controlled analgesia for a postoperative patient. d. Assessment of vital signs in a patient receiving epidural analgesia. 2 ` ANS: A A massage may be delegated to an NAP. Pain assessment is a nursing function and cannot be delegated to an NAP. Administration of patient-controlled analgesia (PCA) cannot be delegated to an NAP. Assessment of vital signs is a licensed nursing function; the NAP can take vital signs for a patient receiving epidural analgesia. 32.A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take? a. Give pain medications around the clock. c. G b iv . e Ap d a min inm is e t d e i r c p a a ti i o n n ma e ft d e i r ca th ti e on pa b in ef i o s re a a 7 n /1 y 0 a o c n tiv th it e y. pain scale. Administer pain medication only when nonpharmacological measures have failed. ANS: A When a patient with arthritis has chronic pain, the best way to manage pain is to take medication regularly throughout the day to maintain constant pain relief. “Before any activity” is nonspecific, and the medication may not have time to work before activity. If the patient waits until having pain (7/10) to take the medication, pain relief takes longer. Nonpharmacological measures are used in conjunction with medications unless requested otherwise by the patient. 33.A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient’s medical record? a. Visceral pain b. Somatic pain c. Centrally generated pain d. Peripherally generated pain ANS: B Somatic pain comes from bone, joint, connective tissue, or muscle. Visceral pain arises from the visceral (internal) organs such as the GI tract and pancreas. Peripherally generated pain in the peripheral nerves can be caused by polyneuropathies or mononeuropathies. Centrally generated pain results from injury to the central or peripheral nervous system, causing deafferentation or sympathetically maintained pain.