Fundamentals Of Nursing NCLEX Quiz 44

1. Which route of administration is preferable for administration of daily analgesics (if all body systems are functional)?

IV

IM or subcutaneous

Oral

Transdermal

PCA

If the gastrointestinal system is function. the oral route is preferred for routine analgesics because of lower cost and ease of administration. Oral route is also less painful and less invasive than the IV. IM. subcutaneous. or PCA routes. Transdermal route is slower and medication availability is limited compared to oral forms.

Explanation

If the gastrointestinal system is function. the oral route is preferred for routine analgesics because of lower cost and ease of administration. Oral route is also less painful and less invasive than the IV. IM. subcutaneous. or PCA routes. Transdermal route is slower and medication availability is limited compared to oral forms.

2. A first day postoperative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take?

Deliver the bolus dose per standing order.

Contact the physician to increase the dose.

Try non-pharmacological comfort measures.

Assess the pain for location. quality. and intensity.

Assess the pain for changes in location. quality. and intensity. as well as changes in response to medication. This assessment will guide the next steps.

Explanation

Assess the pain for changes in location. quality. and intensity. as well as changes in response to medication. This assessment will guide the next steps.

3. In caring for clients with pain and discomfort. which task is most appropriate to delegate to the nursing assistant?

Assist the client with preparation of a sitz bath.

Monitor the client for signs of discomfort while ambulating

Coach the client to deep breathe during painful procedures

Evaluate relief after applying a cold application.

The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client. teaching techniques. and evaluating outcomes are nursing responsibilities.

Explanation

The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client. teaching techniques. and evaluating outcomes are nursing responsibilities.

4. Which non-pharmacological measure is particularly useful for a client with acute pancreatitis?

Diversional therapy. such as playing cards or board games

Massage of back and neck with warmed lotion

Side-lying position with knees to chest and pillow against abdomen

Transcutaneous electrical nerve stimulation (TENS)

The side-lying. knee-chest position opens retroperitoneal space and provides relief. The pillow provides a splinting action. Diversional therapy is not the best choice for acute pain. especially if the activity requires concentration. TENS is more appropriate for chronic muscular pain. The additional stimulation of massage may be distressing to the client.

Explanation

The side-lying. knee-chest position opens retroperitoneal space and provides relief. The pillow provides a splinting action. Diversional therapy is not the best choice for acute pain. especially if the activity requires concentration. TENS is more appropriate for chronic muscular pain. The additional stimulation of massage may be distressing to the client.

5. Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic ladder. (1. Morphine. hydromorphone. acetaminophen and lorazepam || 2. NSAIDs and corticosteroids || 3. Codeine. oxycodone and diphenhydramine)

3 ,2 ,1

2 ,3 ,1

1 ,2 ,3

1 ,3 ,2

Step 1 includes non-opioids and adjuvant drugs. Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs as needed. Step 3 includes opioids for severe pain (replacing Step 2 opioids) and continuing Step 1 drugs and adjuvant drugs as needed.

Explanation

Step 1 includes non-opioids and adjuvant drugs. Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs as needed. Step 3 includes opioids for severe pain (replacing Step 2 opioids) and continuing Step 1 drugs and adjuvant drugs as needed.

6. A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?

Fever

Nausea

Diaphoresis

Abdominal cramps

Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever. nausea. and abdominal cramps are late signs that occur between 48 and 72 hours.

Explanation

Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever. nausea. and abdominal cramps are late signs that occur between 48 and 72 hours.

7. The physician has ordered a placebo for a chronic pain client. You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take?

Prepare the medication and hand it to the physician

Check the hospital policy regarding use of the placebo.

Follow a personal code of ethics and refuse to give it.

Contact the charge nurse for advice.

The charge nurse is a resource person who can help locate and review the policy. If the physician is insistent. he or she could give the placebo personally. but delaying the administration does not endanger the health or safety of the client. While following one’s own ethical code is correct. you must ensure that the client is not abandoned and that care continues.

Explanation

The charge nurse is a resource person who can help locate and review the policy. If the physician is insistent. he or she could give the placebo personally. but delaying the administration does not endanger the health or safety of the client. While following one’s own ethical code is correct. you must ensure that the client is not abandoned and that care continues.

8. A client appears upset and tearful. but denies pain and refuses pain medication. because "my sibling is a drug addict and has ruined out lives." What is the priority intervention for this client?

Encourage expression of fears on past experiences.

Provide accurate information about use of pain medication.

Explain that addiction is unlikely among acute care clients.

Seek family assistance in resolving this problem.

This client has strong beliefs and emotions related to the issue of sibling addiction. First. encourage expression. This indicated to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important. bearing in mind that their beliefs about drug addiction may be similar to those of the client.

Explanation

This client has strong beliefs and emotions related to the issue of sibling addiction. First. encourage expression. This indicated to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important. bearing in mind that their beliefs about drug addiction may be similar to those of the client.

9. Which client is at greater risk for respiratory depression while receiving opioids for analgesia?

An elderly chronic pain client with a hip fracture

A client with a heroin addiction and back pain

A young female client with advanced multiple myeloma

A child with an arm fracture and cystic fibrosis

At greatest risk are elderly clients. opiate naïve clients. and those with underlying pulmonary disease. The child has two of the three risk factors.

Explanation

At greatest risk are elderly clients. opiate naïve clients. and those with underlying pulmonary disease. The child has two of the three risk factors.

10. For a cognitively impaired client who cannot accurately report pain. what is the first action that you should take?

Closely assess for nonverbal signs such as grimacing or rocking.

Obtain baseline behavioral indicators from family members.

Look at the MAR and chart. to note the time of the last dose and response.

Give the maximum PRS dose within the minimum time frame for relief.

Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained. the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.

Explanation

Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained. the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.