HESI PN COMPREHENSIVE PREDICTOR EXAM

1. A nurse is caring for a group of patients. Which patient will the nurse see first? A. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg B. A patient lying very still in bed who reports no pain but is pale with warm, dry skin C. Apatient with severe pain who is nauseated and feels like he or she is about to vomit D. patient writhing and moaning from abdominal pain after abdominal surgery ANS: A A respiratory rate of 10 indicates respiratory depression. A rare adverse effect of opioids in opioid-naïve patients (patients who have used opioids around the clock for less than approximately 1 week) is respiratory depression. Naloxone (Narcan) may be administered. While the other patients are experiencing pain and do need to be seen, they are not the priority since respirations are not affected. 2. A nurse is caring for a patient with chronic pain. Which statement by the nurse indicates an understanding of pain management? “This patient says the pain is a 5 but is not acting like it. I am not a. going to give any pain medication.” “I need to reassess the patient’s pain 1 hour after administering oral b. pain medication.” “It wasn’t time for the patient’s medication, so when it was requested, c. I gave a placebo.” d. “The patient is sleeping, so I pushed the PCA button.” ANS: B Be sure to evaluate after an appropriate period of time. For instance, oral medications usually peak in about 1 hour, whereas IVP medications peak in 15 to 30 minutes. Ask a patient if a medication alleviates the pain when it is peaking. Because oral medications usually peak in about an hour, you need to reassess the patient’s pain within an hour of administration. Nurses must believe any patient report of pain, even if nonverbal communication is not consistent with pain ratings. The patient is the only person who should push the PCA button. Pushing the PCA when a patient is sleeping is dangerous and may lead to narcotic overdose or respiratory depression. Giving the patient a placebo and telling the patient it is medication is unethical.