Week 7 sherpath Flashcards by Monica Galvan-Valencia

Which cues would the nurse use to determine a patient’s safety needs?

Select all that apply.

Subjective data related to the patient’s symptoms

Patient’s family history

Subjective information about the patient’s chief complaint

Patient’s history of exposures to environmental hazards

Objective assessment focused on the affected body systems

Subjective data related to the patient’s symptoms

Subjective information about the patient’s chief complaint

Patient’s history of exposures to environmental hazards

Objective assessment focused on the affected body systems

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To specifically assess the patient’s safety risks related to health issues, which question would the nurse ask?

What safety concerns do you have?

Have you ever had a seizure?

Who else lives with you?

Do you require assistance with bathing?

Have you ever had a seizure?

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Which question would the nurse ask to assess a patient’s understanding of the risks of chemicals?

Where do you store your household cleaners?

Do you know why you take your current set of medications?

Are separate cutting surfaces used for cutting raw fish and meats?

Do you have any safety concerns at home or work?

Where do you store your household cleaners?

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Educating patients about electrical cord safety is important in preventing which specific home safety hazard?

Fire

Outdoor safety hazards

Carbon monoxide poisoning

Biohazards

Fire

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To assess the patient’s risk for exposure to biohazards in the home, which question would the nurse ask?

Do you have air conditioning?

What recreational activities do you engage in?

Is there adequate outside lighting?

Do you or does anyone in the home use hypodermic needles?

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Which member of the interprofessional team would the nurse consult to evaluate a patient for safe performance of activities of daily living (ADLs)?

Social worker

Physical therapist

Occupational therapist

Unlicensed assistive personnel

Occupational therapist

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Which member of the interprofessional team would the nurse consult to evaluate a patient who is a fall risk?

Health care provider

Physical therapist

Occupational therapist

Unlicensed assistive personnel

Physical therapist

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During an assessment, the nurse learns that a patient and child are living in a car. Which member of the interprofessional team would the nurse consult with to evaluate these individuals?

Health care provider

Social worker

Physical therapist

Occupational therapist

Social worker

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A fire prevention plan must include changing batteries in smoke alarms (detectors) at least every

___ months.

6 months

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Many hospitals use the acronym RACE to describe emergency fire response. Which terms stand for the letters in RACE?

Rescue, Advise, Comfort, Expedite

Rescue, Alarm, Contain, Extinguish

Restrain, Action, Continue, Emergency

Resuscitate, Action, Control, Emergency

Rescue, Alarm, Contain, Extinguish

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Which action would the nurse take first when discovering a fire in a patient’s room?

Extinguish the fire.

Contain the fire.

Remove the patient from the room.

Sound the alarm

Remove the patient from the room.

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The nurse is caring for a 72-year-old patient who is on bed rest after hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. Upon assessment, the nurse notes an intravenous (IV) infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient’s total score?

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The nurse is asking the patient a series of questions about the patient’s activities of daily living. The patient asks the nurse why that information is important. Which nursing response is appropriate?

“The answers to these questions will help us determine if you need any assistance at home.”

“This information will help your health care provider determine if you need to be placed in a skilled nursing facility.”

“The questions are designed to get you to think about going home from the hospital.”

“This is part of our regular patient assessment form that we must complete.”

“The answers to these questions will help us determine if you need any assistance at home.”

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A patient is on a large number of medications, and the nurse is concerned about the patient’s personal ability to manage taking all the medications at home. Which questions would the nurse ask to assess the patient’s potential safety risk?

Select all that apply.

“Do you take your medications consistently?”

“Do any young children live in the home who know about - your medications?”

“Do you know how to take these prescriptions?”

“Do you know when to take your drugs?”

“Do you know why the health care provider has prescribed these medications?”

Do you take your medications consistently?”

“Do you know how to take these prescriptions?”

“Do you know when to take your drugs?”

“Do you know why the health care provider has prescribed these medications?”

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A patient with paraplegia is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment?

“Do you have a carbon monoxide detector?”

“Do you have a plan to exit the home in case of an emergency?”

“Where are your medications stored?”

“Do you have a fire extinguisher?”

“Do you have a plan to exit the home in case of an emergency?”

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Which factor is a patient-related fall risk hazard?

Wound drain

Floor surfaces

Intravenous access

Incontinence

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The nurse is planning care for a patient who is 70 years old, lives at home with her healthy 50-year-old daughter, and swims and walks daily. When the patient says she wants to learn more about staying safe at home, which need would the nurse identify as the priority?

Fall prevention

Drowning precautions

Preventing methicillin-resistant Staphylococcus aureus (MRSA)

Avoidance of hypothermia

Fall prevention

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A 90-year-old patient taking multiple medications is being discharged to home. Which members of the interprofessional team would the nurse consult with to evaluate fall risk?

Select all that apply.

Pharmacist

Social worker

Physical therapist

Unlicensed assistive personnel

Occupational therapist

Pharmacist

Physical therapist

Occupational therapist

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The nurse identifies that a patient has difficulty putting on shoes and buttoning a shirt after the examination. Which goal would the nurse create as part of the plan of care?

Patient will select appropriate clothing to wear.

Patient will put on shoes and button shirt.

Patient will perform own activities of daily living (ADLs).

Patient will dress self within 1 month.

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The nurse is educating a patient about home safety. Which patient response indicates that further nursing teaching is required?

“My electrical outlets have covers on them.”

“I shave with my electric razor when I am in the tub for convenience.”

“There is a fire extinguisher in the kitchen.”

“I have smoke detectors in each room.”

“I shave with my electric razor when I am in the tub for convenience.”

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The nurse is admitting a patient who is a fall risk. Which room will the nurse assign?

Room at the end of the hallway

Room nearest the nurses’ station

Double room with a roommate

Room in the middle of the hallway

Room nearest the nurses’ station

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The nurse is evaluating a patient’s understanding of home safety measures. Which patient response indicates that teaching has been effective?

“I checked my floorboards to make sure they are even.”

“I only need to use my cane when I leave the house.”

“I don’t like night-lights because they keep me awake.”

“I throw my used diabetic needles into a soda can when I am done with them.”

“I checked my floorboards to make sure they are even.”

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Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed?

Place the patient on complete bed rest.

Initiate a fall prevention plan for the patient.

Start passive range-of-motion exercises twice a day.

Make sure the patient only ambulates with a walker.

Initiate a fall prevention plan for the patient.

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Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Allow the patient to dangle.

Stand the patient up with assistance.

Transfer the patient with a slide board.

Place the transfer belt after the patient stands

Allow the patient to dangle.

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Match each type of exercise to its example. Ambulating Kegel exercises Heavy weight-lifting Repeated stair-climbing Answer choices Isotonic Anaerobic Isometric Aerobic

Ambulating Isotonic Kegel exercises Isometric Heavy weight-lifting Anaerobic Repeated stair-climbing Aerobic

Which interventions would the nurse implement for a patient with lower extremity Paralysis? Select all that apply. Apply oxygen. Turn every 2 hours. Arrange for a special bed. Use a gait belt for transfers and ambulation. Perform range-of-motion (ROM) exercises at least two times per day.

Turn every 2 hours. Arrange for a special bed. Perform range-of-motion (ROM) exercises at least two times per day.

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving? Ambulates 15 feet with shortness of breath Has a heart rate of 110 beats/min when ambulating Brushes hair while sitting in chair with assistance Has a pulse oximetry reading of 94% when standing to brush teeth

Has a pulse oximetry reading of 94% when standing to brush teeth

Which instruction would the nurse share with the patient about coughing techniques? Fully inhale between coughs. Take two deep breaths in and out to start. Inhale through the nose as deeply as possible. Exhale slowly through the spirometer’s mouthpiece.

Take two deep breaths in and out to start.

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)? Ensure the fit of the sleeves is tight. Roll the sleeves inside out to apply them. Activate the heating feature once a shift. Monitor the patient’s toes for impaired circulation.

Monitor the patient’s toes for impaired circulation.

Which action would the nurse take to improve an immobile patient’s nutritional intake? Monitor the patient’s serum albumin. Assess the patient’s nutritional intake. Allow the patient to make food choices. Weigh the patient at routine intervals.

Allow the patient to make food choices.

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining? Select all that apply. Has a reddened area on hip that will not blanch Has dry, warm, intact skin Has a Braden Scale score that indicates a high risk for skin breakdown Develops a Stage 1 pressure injury on the buttocks Develops a Stage 2 pressure injury on the left hip

Has a Braden Scale score that indicates a high risk for skin breakdown Develops a Stage 1 pressure injury on the buttocks Develops a Stage 2 pressure injury on the left hip

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle? Encourage contact with family and friends. Provide a clock in the patient’s room. Open the window blinds during the day. Allow access to the radio.

Open the window blinds during the day.

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity? Dietitian Primary health care provider Occupational therapist Unlicensed assistive personnel

Unlicensed assistive personnel

In which area would the nurse place a pillow for a patient in the supine position? Between the legs Under the calves Between the arms Under the scapula

Under the calves

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed? Trapeze bar Mechanical lift Transfer board Friction-reducing sheet

Trapeze bar

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation? Cane Walker Crutches Trochanter roll

Walker

Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement? Improves mood Minimizes joint flexibility Promotes muscle strength Stimulates bone reabsorption

Promotes muscle strength

In which position would the nurse place the patient to perform coughing and deep breathing? Dorsal recumbent Fowler’s Side-lying Sim’s

Fowler’s

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility? Ensures that no more than 35 lb (15.9 kg) is placed in the lift Has the patient grab the bars for stability Transfers the patient toward the weaker side Obtains two unlicensed assistive personnel to help

Obtains two unlicensed assistive personnel to help

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills? Place the patient flat in bed. Encourage the patient to take deep breaths. Assess the patient for signs of deep vein thrombosis. Notify the health care provider that the patient may have pneumonia.

Notify the health care provider that the patient may have pneumonia.

Which action would the nurse take for a patient on bed rest who is concerned about developing constipation? Increase the patient’s dietary fiber and fluid intake. Complete the Braden Scale assessment tool. Increase the frequency of passive range-of-motion exercises. Administer enoxaparin prophylactically.

Increase the patient’s dietary fiber and fluid intake.

Which interventions would the nurse select for a patient who is on bed rest? Select all that apply. Have the patient shift weight every 15 minutes while awake. Have the unlicensed assistive personnel teach about the importance of mobility. Reduce hallway light at night. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot. Turn patient every 4 hours.

Have the patient shift weight every 15 minutes while awake. Reduce hallway light at night. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot.

Which actions would the nurse take for a patient who is immobile? Select all that apply. Encourage at least 1500 mL of fluid daily. Suggest drinking at least 2000 mL during a 24-hour period. Encourage passive range-of-motion exercises. Place high-top tennis shoes on feet. Reposition at least once every 8 hours.

Suggest drinking at least 2000 mL during a 24-hour period. Encourage passive range-of-motion exercises. Place high-top tennis shoes on feet.

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility? Select all that apply. Use the incentive spirometer 5 to 12 times every 1 to 2 hours. Deep breathe 10 times every hour. Cough two to three times every 2 hours. Perform range-of-motion exercises at least five to six times each day. Move each joint three to five times during range-of-motion exercises.

Use the incentive spirometer 5 to 12 times every 1 to 2 hours. Deep breathe 10 times every hour. Cough two to three times every 2 hours. Move each joint three to five times during range-of-motion exercises.

Which safety measures would the nurse implement for a patient who is a fall risk? Select all that apply. Use a low bed. Place in a room away from the nurses’ station for quietness. Raise all four side rails. Frequently orient the patient. Place floor mats beside the bed.

Use a low bed. Frequently orient the patient. Place floor mats beside the bed.

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse? Select all that apply. Refuses to massage a patient’s leg with deep vein thrombosis Places a gait belt on a patient with osteoporosis to assist with ambulation Allows the patient’s elbows to be bent at a 45-degree angle when using a cane Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg Has the patient cough two times after using an incentive spirometer

Places a gait belt on a patient with osteoporosis to assist with ambulation Allows the patient’s elbows to be bent at a 45-degree angle when using a cane Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating? Select all that apply. Experiences a pulmonary embolus Has dusky toes Has coagulation laboratory results that indicate the patient is clotting too fast States the sequential compression device pressure is maintained at 40 mm Hg Experiences intact skin with no abnormalities in the lower leg

Experiences a pulmonary embolus Has dusky toes Has coagulation laboratory results that indicate the patient is clotting too fast

Which cues alert the nurse that the patient with Paralysis is declining? Select all that apply. Develops disuse osteoporosis Has not lost muscle mass Does not participate in physical therapy Controls wheelchair according to capabilities Avoids muscle atrophy

Develops disuse osteoporosis Does not participate in physical therapy

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving? Select all that apply. Needs a one-person assist to ambulate Needs no assistance to transfer Ambulates unassisted down the corridor and back Needs a two-person assist to walk to the bathroom Ambulates with no slips on the floor

Needs no assistance to transfer Ambulates unassisted down the corridor and back Ambulates with no slips on the floor

Which actions would the nurse take if the patient falls while ambulating in the hall? Select all that apply. Call for help. Assess the patient’s physical and neurologic status. Notify charge nurse and primary health care provider. Leave the patient to go get help. Complete occurrence report.

Call for help. Assess the patient’s physical and neurologic status. Notify charge nurse and primary health care provider. Complete occurrence report.

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient? Select all that apply. Leave top side rails up. Bend at the knees. Carry weight close to the body. Use mechanical lift equipment. Relax pelvic muscles.

Leave top side rails up. Bend at the knees. Carry weight close to the body. Use mechanical lift equipment.

The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number.

2 hours

Place the steps in the order the nurse would follow to teach a patient how to use a cane. Move the stronger leg. Move the weaker leg. Place cane on the patient’s stronger side. Move the cane.

Place cane on the patient’s stronger side. Move the cane. Move the weaker leg. Move the stronger leg.

Which aspects would the nurse consider when conducting a pain assessment for a patient in a non–life-threatening situation? Select all that apply. Health literacy does not influence the assessment. The nurse should complete the assessment as quickly as possible. The patient’s values and beliefs about pain affect the assessment. The nurse’s values and beliefs about pain may influence the assessment. A calm and supportive manner promotes effective communication.

The patient’s values and beliefs about pain affect the assessment. The nurse’s values and beliefs about pain may influence the assessment. A calm and supportive manner promotes effective communication.

Which scenario describes when a nurse would perform a focused pain assessment on a patient? Anytime a patient is at high risk for pain Before taking vital signs and the patient reports the pain is mild After taking vital signs and the patient reports the pain is mild After taking vital signs and the patient reports the pain is severe

After taking vital signs and the patient reports the pain is severe

Which pain assessment tools utilize verbal reports from the patient? Select all that apply. 0–10 Pain Scale Neonatal Infant Pain Scale Universal Pain Tool Wong-Baker Scale Pain Assessment in Advanced Dementia Scale

0–10 Pain Scale Universal Pain Tool Wong-Baker Scale

Which technology innovations can the nurse use to accurately assess or manage pain? Select all that apply. Informatics Pharmacogenomics Neuroimaging biomarkers Noncognitive assessment tools Magnetic resonance imaging

Informatics Pharmacogenomics Neuroimaging biomarkers Magnetic resonance imaging

Match the body system to the associated physiologic alteration caused by pain. Decreases air exchange Increases oxygen demand Develops spasms, tension, and fatigue Releases hormones such as cortisol, glucagon, and insulin Answer choices Cardiovascular Respiratory Endocrine Muscular

Decreases air exchange Respiratory Increases oxygen demand Cardiovascular Develops spasms, tension, and fatigue Muscular Releases hormones such as cortisol, glucagon, and insulin Endocrine

Match the body system to the associated physiologic alteration caused by pain. Decreases motility and emptying Releases inflammatory mediators Increases blood pressure through release of hormones Answer choices Urinary Gastrointestinal Immune

Decreases motility and emptying Gastrointestinal Releases inflammatory mediators Immune Increases blood pressure through release of hormones Urinary

Which cue would the nurse anticipate when assessing a patient experiencing pain? Diarrhea Indigestion Weight gain Increased bowel sounds

Indigestion

Which cues are behavioral indications of pain? Select all that apply. Fear Moaning Agitation Depression Clenching teeth

Moaning Agitation Clenching teeth

Which aspects reflect key considerations for the nurse to effectively recognize cues related to pain? Select all that apply. Culture Urgency Relevance Physiology Importance

Urgency Relevance Importance

Which action allows the nurse to begin collecting cues about a burn patient’s pain experience? Performing comfort measures Taking the patient’s vital signs Recording the patient’s meal order Removing the dressings to assess the wound

Taking the patient’s vital signs

Which questions would the nurse ask when conducting a pain assessment for a trauma patient? Select all that apply. “Where is the pain located?” “Where did the trauma occur?” “What makes the pain worse or better?” “Does the pain radiate anywhere?” “On a scale from 1 to 50, how would you rate your pain?”

“Where is the pain located?” “What makes the pain worse or better?” “Does the pain radiate anywhere?”

A nurse is conducting a pain assessment using the SOCRATES acronym. Which concept reflects the meaning of the letter “T” in SOCRATES? Time course Type of pain Temperature Time of onset

Time course

The nurse assesses the patient’s pain using the SOCRATES acronym. Which additional question would be relevant to the pain assessment? “Where is the pain located?” “Is the pain stabbing, burning, or aching?” “Does anything make the pain worse or lessen it?” “What are your past pain experiences?”

“What are your past pain experiences?”

The nurse working in an urgent care office assesses a patient who presents with a possible broken ankle that is edematous. The patient rates the pain a 9 on a 0–10 scale. The nurse obtains vital signs and notices that the patient grimaces every time the affected foot moves. Which cue reflects subjective data? Vital signs Edematous ankle Weak pulse in the foot Pain rating of 9 on a 0–10 scale

Pain rating of 9 on a 0–10 scale

The nurse asks a patient experiencing painful kidney stones to rate the pain on a scale from 0 to 10. The patient rates the pain as a 7. Which phrase describes the patient’s level of pain indicated by the rating? Mild pain Severe pain Average pain Moderate pain

Severe pain

Which statement reflects how the gastrointestinal system responds to pain? Releases extra gas Speeds metabolism Increases gastric emptying Decreases intestinal motility

Decreases intestinal motility

Which statement describes how pain experienced by postoperative patients increases the risk for development of pneumonia? Inhibits the inflammatory response Causes a reluctance to breathe deeply Increases mucus as a result of emotional reaction and crying Releases insulin, causing diabetes and decreased oxygenation

Causes a reluctance to breathe deeply

Which patient cues are indicative of chronic pain? Select all that apply. Dilated pupils Constricted pupils Increased heart rate Decreased heart rate Increased systolic blood pressure Decreased systolic blood pressure

Constricted pupils Decreased heart rate Decreased systolic blood pressure

A patient with diabetes presents at the emergency department with a broken arm and pain rated 8 on a 0–10 pain scale. Which effect on the patient’s blood glucose would be anticipated? Increased blood glucose level Decreased blood glucose level Fluctuating blood glucose level No effect on blood glucose level

Increased blood glucose level

Which cue reflects that the patient is experiencing pain? Hypoglycemia Decreased urine output Reduced respiratory rate Loose bowel movements

Decreased urine output

Which cues are psychological expressions of pain? Select all that apply. Fear Crying Agitation Depression Helplessness Facial grimacing

Fear Depression Helplessness

Which cues are relevant to the adult patient’s acute pain experience? Select all that apply. Dilated pupils Heart rate of 120 Respiratory rate of 12 Blood pressure of 118/62 Pain rated 7 on 0–10 pain scale

Dilated pupils Heart rate of 120 Pain rated 7 on 0–10 pain scale

Which actions support the nurse’s role in pain management? Select all that apply. Assessing the patient’s pain level Educating the patient about pain relief options Evaluating patient response to pain interventions Using medication as the primary treatment for pain management Advocating with the health care provider for pain relief for the patient

Assessing the patient’s pain level Educating the patient about pain relief options Evaluating patient response to pain interventions Advocating with the health care provider for pain relief for the patient

Which statements reflect The Joint Commission’s (TJC’s) pain assessment standards? Select all that apply. Document the comprehensive pain assessment. Provide nonpharmacologic pain treatment modalities. Address pain assessment and management with new staff. Develop an evidence-based and standardized pain treatment plan. Monitor patients at high risk for adverse outcomes related to opioid treatment.

Provide nonpharmacologic pain treatment modalities. Address pain assessment and management with new staff. Monitor patients at high risk for adverse outcomes related to opioid treatment.

Match the nursing action to the related descriptive statement. Look for adverse effects of prescribed medication. Share information about potential adverse effects and usages. Consider the effectiveness of pain management interventions. Provide clear documentation in the patient’s record. Answer choices Assess Communicate Evaluate Educate

Look for adverse effects of prescribed medication. Assess Share information about potential adverse effects and usages. Educate Consider the effectiveness of pain management interventions. Evaluate Provide clear documentation in the patient’s record. Communicate

Which actions are considered nonpharmacologic pain management interventions the nurse can perform without a prescription from a health care provider? Select all that apply. Patient repositioning Using distraction techniques Educating about opioid dependence Postoperative splinting Using progressive relaxation techniques

Patient repositioning Using distraction techniques Postoperative splinting Using progressive relaxation techniques

Match the nonpharmacologic therapies with the appropriate description. Has pain-relieving properties Restores a calm state, promoting relaxation Helps build strength, and balance body and mind Trains the body for voluntary control to relieve pain Answer choices Meditation Biofeedback Yoga Herbs

Has pain-relieving properties Herbs Restores a calm state, promoting relaxation Meditation Helps build strength, and balance body and mind Yoga Trains the body for voluntary control to relieve pain Biofeedback

Which traditional Chinese therapy is often associated with nonpharmacologic pain relief? Massage Hypnosis Acupuncture Nerve stimulation

Acupuncture

Which pain management strategy is a neurologic therapy? Distraction Positioning Nerve stimulation Massage therapy

Nerve stimulation

Which statement describes multimodal analgesia? Two or more medications are used to relieve pain. More than one intervention is used to control pain. Pain medication is used in anticipation of a painful event. Pharmacologic and nonpharmacologic strategies are combined.

Two or more medications are used to relieve pain.

Which characteristic of non-opioid analgesic medications describes why nurses administer them more often than opioid analgesics? Easier to dispense Safer for the patient Cheaper to dispense Prescription not required

Safer for the patient

Which statement describes a benefit of patient-controlled analgesia (PCA)? Patients can self-administer and manage their pain medication. Patients’ families can administer medication whenever desired. Patients can give themselves as much medication as they desire. The nurse does not have to perform a check before administration.

Patients can self-administer and manage their pain medication.

Which statement by the new nurse indicates understanding of the nurse’s role in pain management? Select all that apply. “I will be sure to educate the patient about pain treatment options.” “I will remember to assess for pain as a part of my initial assessment.” “I will perform a cardiac assessment to complete proper pain management procedures.” “I must advocate for adequate pain relief for my patient if current therapies seem - ineffective.” “I must evaluate the patient’s response to interventions to deliver focused patient care.”

“I will be sure to educate the patient about pain treatment options.” “I will remember to assess for pain as a part of my initial assessment.” “I must advocate for adequate pain relief for my patient if current therapies seem - ineffective.” “I must evaluate the patient’s response to interventions to deliver focused patient care.”

Which statement reflects the purpose of the Rights of Medication Administration? Facilitate the discharge process Prevent medication errors Increase patient satisfaction scores Aid the health care provider in prescribing the correct medication

Prevent medication errors

The nurse tells a patient that oxycodone can cause itchiness and sleepiness and that it must be taken only as prescribed. The nurse also recommends taking a stool softener with this medication as it may cause constipation. Which action is the nurse demonstrating? Education Evaluation Assessment Intervention

Education

The health care provider prescribes an oral analgesic every 4 hours as needed for pain. At hour 3, the patient still complains of severe pain rated 8 on a 0–10 scale and verbalizes feelings of frustration as a result of lack of pain relief. Which action is most effective for the nurse to take while awaiting a prescription for an increase in pain medication? Telling the patient to try to relax and rest Turning on the TV to provide a distraction for the patient Implementing massage and positioning techniques Conversing with the patient to draw attention away from the pain

Implementing massage and positioning techniques

A patient who is in labor reports intense, painful contractions and feels very nauseous. The patient wants to proceed without the use of medication. Which nonpharmacologic interventions can the nurse implement for this patient? Select all that apply. Repositioning the patient Massaging the patient’s back Assisting with deep breathing exercises Consulting with the patient’s birthing doula Keeping the patient hydrated with clear liquids

Repositioning the patient Massaging the patient’s back Assisting with deep breathing exercises

A patient is 2 days post–knee surgery. The pain management plan includes pharmacologic treatment, but the patient also requests nonpharmacologic methods, so the nurse brings the patient an ice pack. Which statement by the nurse indicates an understanding of the use of cold therapy to treat pain? “Thermotherapy provides local analgesia.” “Ice packs should be applied for up to 1 hour.” “Rest periods from cold therapy should be provided to prevent tissue injury.” “Cryotherapy is effective for pain management because it speeds nerve conduction.”

“Rest periods from cold therapy should be provided to prevent tissue injury.”

A patient who presents to the emergency department with mild leg strain requests nonpharmacologic pain treatment. Which alternative therapies would the nurse suggest? Select all that apply. Yoga Aspirin Exercise Meditation Biofeedback

Yoga Meditation Biofeedback

A patient has a broken femur and is in excruciating pain. The health care provider prescribes an intravenous opioid and acetaminophen combination for pain relief. Which statement explains why the two medications are prescribed for pain? Select all that apply. The mixture of medications produces fewer side effects. Multimodal analgesia requires lower doses for effective pain relief. The health care provider wants to avoid an unhappy patient call later complaining of unrelieved pain. The combination of medications is more effective than just the opioid alone. The choices of medications allow the nurse to select the best option based on patient preference.

The mixture of medications produces fewer side effects. Multimodal analgesia requires lower doses for effective pain relief. The combination of medications is more effective than just the opioid alone.

A patient is prescribed a nonsteroidal antiinflammatory drug (NSAID) for arthritis. The nurse would educate the patient about which potential side effects? Select all that apply. Inflammation Hepatotoxicity Increased bleeding Decreased heart rate Gastrointestinal upset Cardiac complications

Increased bleeding Gastrointestinal upset Cardiac complications

A patient rates pain a 9 on a 0–10 scale and requests pain medication. The nurse reviews the medication administration record (MAR) and finds oxycodone, ibuprofen, acetaminophen, and ketorolac are prescribed. Which medication would the nurse administer? Ketorolac Ibuprofen Oxycodone Acetaminophen

Oxycodone

The nurse gives a patient a dose of intravenous morphine for pain relief. A few minutes later, the patient’s respiratory rate is 5 breaths/min. Which medication would the nurse administer to reverse the effects of the opioid? Naloxone Dezocine Fentanyl Hydromorphone

Naloxone

Which action is eliminated by the use of patient-controlled analgesia (PCA) pumps? Assessing the patient’s pain Requesting other types of pain medication Educating the patient regarding pain management Waiting for the nurse to administer pain medication

Waiting for the nurse to administer pain medication

A patient is admitted to the hospital with a broken hip, and the health care provider prescribes a patient-controlled analgesia (PCA) system to manage the pain. Which patient statement reflects understanding of education about the use of PCA provided by the nurse? “This PCA machine dispenses a pill every time I push the button.” “I will be able to give myself pain medication any time I feel that I need it.” “This infusion pump is programmed to give me a set dose of medication at a set time interval.” “This infusion pump is controlled by a button, and if I can’t hit the button my family can do it for me.”

“This infusion pump is programmed to give me a set dose of medication at a set time interval.”

The nurse provides literature to a patient about side effects and activities to avoid while taking a prescribed medication. Which nursing action is demonstrated when the nurse asks the patient to repeat back the information? Analyzing Assessing Evaluating Understanding

Assessing