Pain
A nurse is assessing a patient who reports pain at a level of 7 on a 0-10 scale. The patient appears calm and is watching television. What is the nurse's best action?
Accept the patient's pain rating and provide appropriate intervention.
Rationale: Pain is a subjective experience, and it is the nurse's responsibility to accept that pain exists when a patient reports it. Patients cannot be expected to "prove" their pain is present. The absence of nonverbal pain behaviors does not mean pain is absent.
A nurse is caring for a patient with chronic arthritis pain. Which nonpharmacological intervention should the nurse include in the care plan to enhance the effects of medication therapy?
Teach the patient relaxation techniques and meditation.
Rationale: Nonpharmacological strategies such as relaxation techniques, visualization, meditation, biofeedback, and TENS units enhance the effects of medication therapy. Drug therapy for pain management should be coupled with comfort measures, relaxation techniques, meditation, and stress management to ensure maintenance of activities of daily living.
A nurse is weighing a hospitalized patient with heart failure. Which action ensures the most accurate daily weight measurement?
Weigh the patient at the same time each day, after voiding, wearing the same clothes, on the same calibrated scale.
Rationale: Daily weights are the most accurate measure of volume status. To ensure accuracy, weigh patients at the same time every day with the same scale (calibrated daily or routinely), after voiding, wearing the same clothes or clothes that weigh the same. Each kilogram (2.2 lb) of weight gained or lost overnight equals 1 L of fluid retained or lost. Consistency in weighing conditions is essential for accurate interpretation of fluid status trends.
A nurse is caring for a patient with fluid volume deficit from vomiting and diarrhea. Which electrolyte imbalance should the nurse anticipate?
Hyponatremia
Rationale: Fluid volume deficit caused by loss of gastrointestinal fluids from vomiting and diarrhea leads to loss of both fluid and electrolytes, particularly sodium. When fluid volume is depleted, it is possible to replace fluids and electrolytes orally or with IV administration. The nurse should monitor for signs of hyponatremia including dizziness, postural hypotension, and increased heart rate on standing.
A healthcare provider orders 0.5 g of an antibiotic. The medication is available in 250 mg tablets. How many tablets should the nurse administer?
2 tablets
Rationale: First, convert grams to milligrams: 0.5 g = 500 mg. Using the formula method:
Formula: (500 mg / 250 mg) × 1 tablet = 2 tablets
Always ensure all measures are in the same measurement system before calculating the dose.
A nursing instructor is teaching students about oxygen therapy. Which statement by a student indicates correct understanding of FiO₂?
A) "FiO₂ is measured in liters per minute"
B) "FiO₂ represents the fraction of inspired oxygen concentration"
C) "Flow rate and FiO₂ percentage are always equal"
D) "FiO₂ is only important for patients on mechanical ventilation"
"FiO₂ represents the fraction of inspired oxygen concentration"
Rationale: FiO₂ (fraction of inspired oxygen) is the percentage or concentration of oxygen delivered to the patient. Flow rate is ordered in liters per minute (L/min), but these numbers do not correlate directly with the percentage of oxygen delivered. The amount of oxygen delivered depends on the type of device used.
A nurse is caring for a postoperative patient experiencing acute severe pain. Which assessment approach is most appropriate?
Assess location, severity, and quality of pain, then conduct a detailed assessment when the patient is more comfortable.
Rationale: During episodes of acute or severe pain, patients have difficulty providing detailed descriptions. The assessment should be streamlined to focus on essential elements (location, severity, quality), with comprehensive assessment completed once pain is better controlled.
A laboring patient who did not attend childbirth preparation classes is becoming increasingly anxious and unable to follow verbal instructions during contractions. What is the nurse's priority action?
Make close eye contact and breathe with the patient through each contraction.
Rationale: When a woman is extremely anxious and out of control, she will not be able to comprehend verbal instructions. It may be necessary to make close eye contact with her and breathe with her through each contraction until she can regain control. Once control is established, simple breathing and relaxation techniques can be taught.
A patient's weight has increased by 2.2 kg overnight. The nurse recognizes this weight gain is equivalent to how much fluid retention?
2 liters (2000 mL)
Rationale: Each kilogram (2.2 lb) of weight gained or lost overnight equals 1 L of fluid retained or lost. An increase of 1 kg equals 1000 mL (1 L) of fluid retention. Therefore, a 2.2 kg weight gain represents approximately 2 L of fluid retention, provided the person has maintained usual dietary intake.
A patient is receiving oral potassium supplements three times daily for hypokalemia. Before administering the morning dose, what assessments must the nurse complete?
Verify that the serum potassium level is normal and that urine output is adequate.
Rationale: Before administering potassium supplements, the nurse must verify that the serum potassium level is normal and that urine output is adequate. If the serum level is elevated or if urine output has decreased, the dose of potassium must be withheld and the health care provider must be consulted. This prevents dangerous hyperkalemia, especially in patients with decreased renal function.
A patient consumed the following during the day shift: 8 oz of coffee, 6 oz of juice, 4 oz of gelatin, and 240 mL of water. What is the patient's total oral intake in mL? (1 oz = 30 mL)
780 mL
Rationale: Fluid intake includes all liquids a person eats (gelatin) or drinks. Convert ounces to mL:
Total: 240 + 180 + 120 + 240 = 780 mL
A medication order is for 0.25 mg per kg. The patient weighs 68 kg. What is the total dose?
17 mg
Multiply: 0.25 × 68 = 17 mg. When multiplying decimals, multiply as if they were whole numbers, then count the total decimal places in both factors (2 places in 0.25) and place the decimal point in the answer accordingly.
When selecting a pain assessment tool for a patient with advanced dementia, what should the nurse consider?
Choose a tool that has been validated for use with adults who have cognitive impairment.
Rationale: Clinical usefulness, reliability, and validity of assessment tools must be considered for specific patient populations. Tools validated for one population may not provide reliable assessments in another. Patients with cognitive impairments require observation of vocal responses, facial movements, and body movements.
A nurse is developing a pain management plan for a patient with persistent pain. Which goal reflects an appropriate understanding of nonpharmacological pain management?
Improve the patient's quality of life and functional capacity.
Rationale: Pain, especially chronic pain, may not be completely eliminated but must be managed. Important therapeutic goals include improving the patient's quality of life, functional capacity, and ability to retain independence. The patient and caregiver should be involved in establishing realistic goals and expectations for pain management.
A nurse is reviewing a patient's 24-hour intake and output record. Intake is 2400 mL and output is 1200 mL. What should the nurse consider when interpreting this data?
The patient may be gaining excessive fluid or returning to normal fluid status by replacing previously lost fluid.
Rationale: When intake is substantially greater than output, there are two possibilities: the patient may be gaining excessive fluid or returning to normal fluid status by replacing fluid lost previously from the body. The nurse must consider the individual patient's clinical context and look at trends over time to determine which situation applies.
A patient with hyponatremia is receiving 3% sodium chloride IV. The serum sodium has increased from 118 mEq/L to 132 mEq/L over 10 hours. What is the nurse's priority concern?
Risk for osmotic demyelination syndrome from rapid sodium correction.
Rationale: The serum sodium level should not increase by more than 10 to 12 mEq/L in the first 24 hours. Quickly increasing sodium levels can cause osmotic demyelination syndrome with permanent damage to nerve cells in the brain. The nurse should monitor serum sodium levels closely and notify the provider to avoid rapid correction or overcorrection.
A healthcare provider orders 0.25 mg of a medication subcutaneously. Which documentation is correct and safe?
0.25 mg
Rationale: Leading zeros (zeros placed before a decimal point) are allowed and required for patient safety. Trailing zeros (zeros following the decimal point) must be avoided. For example, 0.25 mg is correct, but 0.250 mg could be misread. The misplacement of decimal points could lead to a tenfold or greater overdose.
A nurse is assessing a patient's chest configuration. Which anteroposterior (AP) to transverse diameter ratio is considered normal?
A. 1:1
B. 1:2
C. 2:1
D. 1:3
1:2
The normal AP ratio is 1:2, meaning the anteroposterior diameter should be less than the side-to-side (transverse) diameter. An increase in AP diameter (approaching 1:1) creates a "barrel chest" appearance, which may result from normal aging or lung hyperinflation conditions like emphysema.
A patient states, "I can walk when my pain is at a 2." What does this assessment information help the nurse determine?
The patient's functional pain goal.
Rationale: Assessing the tolerable level of pain that allows patients to function is essential. The goal is to help patients regain pain control at a level that permits necessary activities, not necessarily complete pain elimination.
A nurse is assessing a postoperative patient from a culture that values stoicism. The patient is lying quietly in bed with a rigid posture and elevated blood pressure. When asked about pain, the patient smiles and rates pain as "2/10." What is the nurse's best action?
Assess for additional pain indicators and explore the cultural meaning of pain with the patient.
Rationale: Cultural beliefs and values affect how individuals cope with and express pain. Some cultures teach that outward expressions of pain are to be avoided, and in some cultures, negative emotions such as pain may be concealed by smiling. Observable indicators including rigid posture and elevated blood pressure suggest pain may be present despite the patient's verbal report. The nurse should explore the impact of culture on the patient's pain experience and how the patient expresses pain, while also assessing for physiological signs such as elevated blood pressure, heart rate, and respirations.
A patient's urine output for the past 8 hours is 180 mL. What is the nurse's priority action?
Report the finding to the charge nurse or primary care provider.
Rationale: Average urine output is less than 30 mL/hour (180 mL ÷ 8 hours = 22.5 mL/hour). An output of less than 30 mL/hour or less than 720 mL in a 24-hour period should be reported to the charge nurse or primary care provider, as this may indicate inadequate kidney perfusion or fluid volume deficit.
A nurse is managing a patient with hypernatremia and sodium excess. Which IV fluid should the nurse anticipate administering?
5% dextrose in water
Rationale: When the problem is sodium excess, treatment includes diluting the high sodium concentration with sodium-free IV fluids, such as 5% dextrose in water, and promoting sodium excretion with diuretics. The serum sodium level should not decrease by more than 8 to 15 mEq/L in an 8-hour period to prevent cerebral edema.
A patient's temperature is 38.5°C. The nurse needs to document this in Fahrenheit. What is the temperature in °F? (Formula: °F = (°C × 9/5) + 32)
101.3°F
Rationale: Using the conversion formula: °F = (38.5 × 9/5) + 32 °F = (38.5 × 1.8) + 32 °F = 69.3 + 32 = 101.3°F
Accurate conversion between measurement systems is essential for safe medication administration and patient assessment.
A patient presents with respiratory distress. Which respiratory rate would the nurse identify as tachypnea in an adult?
A. 10 breaths/min
B. 16 breaths/min
C. 20 breaths/min
D. 26 breaths/min
26 breaths/min
The normal adult respiratory rate is 12 to 20 breaths/min. A rate above 20 breaths/min is considered tachypnea and may indicate respiratory distress or other pathology.
Which assessment finding requires immediate follow-up in an older adult with persistent pain?
Decreased mobility and impaired balance.
Rationale: Mobility assessment is critical because pain and some analgesics can affect fall risk. The nurse must assess the effects pain has on mobility and balance, especially in older adults.
A nurse observes that a patient is moaning loudly and crying out frequently after surgery. The patient's family states, "In our culture, it is acceptable to express pain openly." What is the most appropriate nursing response?
"I understand. Let me assess your family member's pain and provide appropriate relief measures."
Rationale: Different meanings and attitudes are associated with pain across various cultural groups. Some cultures teach that it is acceptable to express pain by crying, moaning, and yelling, and these individuals expect relief from pain as quickly as possible. Nurses who are from cultures that value stoicism may become upset with more demonstrative behavior, but an understanding of the cultural meaning of pain helps design culturally sensitive care. The nurse should avoid assuming everyone responds to pain in the same way and should provide adequate pain management regardless of expression style.
Which items should the nurse include when calculating a patient's 24-hour fluid intake?
Gelatin, ice cream, IV fluids, tube feeding, and liquid medications.
Rationale: Fluid intake includes all liquids a person eats (gelatin, ice cream, soup), drinks (water, coffee, juice), or receives through feeding tubes. IV fluids, blood components, water taken with pills, and liquid medications all count as intake. Over 24 hours, these liquids amount to significant intake and must be documented on the I&O record.
A patient receiving oral potassium supplements reports nausea and muscle weakness. The nurse notes a serum potassium level of 5.8 mEq/L. What is the nurse's priority action?
Withhold the potassium supplement and notify the healthcare provider.
Rationale: Hyperkalemia symptoms include fatigue, muscle weakness, confusion, and nausea. Normal potassium level is 3.5-5 mg/dL. When hyperkalemia is indicated (potassium >5.5 mmol/L), the product should be reduced or discontinued. The nurse should notify the prescriber immediately and monitor for ECG changes including peaked T waves, lowered R, depressed RST, prolonged P-R interval, and widening QRS complex.
A healthcare provider orders 500 mg of amoxicillin IM. The medication is available as 100 mg/1 mL. How many mL should the nurse administer?
5 ml
A patient scheduled for surgery tells the nurse, "I don't really understand what the surgeon explained about the risks of this procedure." What is the nurse's best action to demonstrate respect for patient autonomy?
A) Reassure the patient that the surgeon knows what is best
B) Explain the risks and benefits of the surgery to obtain consent
C) Support the patient in requesting additional information from the surgeon
D) Encourage the patient to sign the consent form and ask questions later
C) Support the patient in requesting additional information from the surgeon
Rationale: Respect for patient autonomy refers to the commitment to include patients in decisions about all aspects of care. Nurses demonstrate respect for patient autonomy by supporting patients who raise questions about procedures and by ensuring that they get the information they request.
Informed consent requires full disclosure of facts the patient needs to make an intelligent decision before any invasive treatment or procedure is performed. The patient has the right to accept or reject proposed care only after understanding fully what is being proposed—the benefits of the treatment, the risks involved, any alternative treatments, and the consequences of refusing the treatment or procedure.
The nurse's role is to advocate for the patient and facilitate communication with the surgeon, not to obtain consent (which is the surgeon's responsibility) or to pressure the patient into signing without full understanding. Conversations with patients can help them articulate their preferences, values, and goals—a key step in making autonomous health care decisions.