Pain
On the first day after surgery, a patient who is on a patient-controlled analgesia pump reports that the pain control is inadequate. Which action would the nurse take first?
1. Deliver the bolus dose per standing order.
2. Contact the health care provider (HCP) to increase the dose.
3. Try nonpharmacologic comfort measures.
4. Assess the pain for location, quality, and intensity.
4. Assess the pain for location, quality, and intensity.
Rationale: During clinical rotations, you may observe nurses giving pain medication without performing an adequate pain assessment. This is an error in clinical performance. In postoperative patients, pain could signal complications, such as hemorrhage, infection, or decreased perfusion related to tissue swelling. Always assess pain first, then make a decision about giving medication, using nonpharmacologic methods, or contacting the HCP.
The patient who is receiving chemotherapy describes a burning sensation in the leg, which the health care provider diagnoses as neuropathic pain secondary to the therapy. The nurse is most likely to question the prescription of which drug?
1. Imipramine
2. Carbamazepine
3. Gabapentin
4. Morphine
4.Morphine
Rationale: Morphine is usually not prescribed for neuropathic pain because pain relief response is poor. Other medications, such as some antidepressants (e.g., imipramine) and some anticonvulsants (e.g., carbamazepine and gabapentin), provide beter relief.
Which finding will be most important for the nurse to report to the health care provider about a patient who is taking prednisone chronically after an organ transplant?
1. Multiple arm bruises
2. Sodium level of 146 mEq/dL (146 mmol/L)
3. Blood glucose of 110 mg/dL (6.1 mmol/L)
4. Black-colored stools
4. Black-colored stools
Rationale: Dark green or black stools may indicate gastrointestinal bleeding, a possible adverse effect of oral steroid use, and further assessment and treatment are needed. Although thinning of the skin, electrolyte disturbances, and changes in glucose metabolism also occur with steroids, bruising and mild changes in sodium or glucose level do not require treatment.
The assistive personnel (AP) reports to the nurse that a patient’s urine output for the past 24 hours has been only 360 mL. What is the nurse’s priority action at this time?
1. Place an 18-gauge IV in the nondominant arm.
2. Elevate the patient’s head of bed at least 45 degrees.
3. Instruct the AP to provide the patient with a pitcher of ice water.
4. Contact and notify the health care provider immediately.
4. Contact and notify the health care provider immediately.
Rationale: The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The patient may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case.
The nurse is caring for a patient with intractable nausea and vomiting. The patient has a temperature of 99°F, a pulse of 100, a respiratory rate of 24, a blood pressure of 90/60, and oxygen saturation of 91%. What is the first action the nurse should take?
1. Start an IV of normal saline.
2. Administer ondansetron 4 mg IV.
3. Apply oxygen at 2 L/min per nasal cannula.
4. Make sure the wall suction is fully functioning.
4. Make sure the wall suction is fully functioning.
Rationale: Airway patency is the priority for this patient and the first thing the nurse should do is take measures to ensure the airway will be patent by making sure suction is readily available. Intractable nausea and vomiting pose a safety risk for aspiration. The other choices are all acceptable actions, but ensuring there is a patent airway is the first thing the nurse should do.
A patient with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal antiinflammatory drugs. Which medication will the nurse advocate for first?
1. Gabapentin
2. Corticosteroids
3. Hydromorphone
4. Lorazepam
1. Gabapentin
Rationale: Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be prescribed as an adjuvant medication.
For a patient with osteogenic sarcoma, which laboratory value causes the most concern?
1. Sodium level of 135 mEq/L (135 mmol/L)
2. Calcium level of 13 mg/dL (3.25 mmol/L)
3. Potassium level of 4.9 mEq/L (4.9 mmol/L)
4. Blood urea nitrogen (BUN) of 10 mg/dL (3.6 mmol/L)
2. Calcium level of 13 mg/dL (3.25 mmol/L)
Rationale:
The normal range for calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Potentially life-threatening hypercalcemia can occur in cancers with destruction of bone. Other laboratory values are pertinent for overall patient management but are less specific to bone cancers. Normal ranges are: sodium 136 to 145 mEq/L (136 to 145 mmol/L); potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); and BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
After a change-of-shift report, which newly admitted patient should the nurse assess first?
1. A patient with human immunodeficiency virus whose CD4 count is 45 mm3(45 cells/mcL)
2. A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due
3. A patient with graft-versus-host disease who has frequent liquid stools
4. A patient with hypertension who has angioedema after receiving lisinopril
4. A patient with hypertension who has angioedema after receiving lisinopril
Rationale: Because angioedema may cause airway obstruction, this patient should be assessed for any difficulty breathing, and treatment should be started immediately. The other patients also will need to be assessed as quickly as possible, but the patient with potential airway difficulty will need the most rapid care.
The nursing plan of care for an older patient with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by an RN? Select all that apply.
1. Reminding the patient to avoid commercial mouthwashes
2. Encouraging mouth rinsing with warm saline
3. Assessing skin turgor by pinching the skin over the back of the hand
4. Observing the lips, tongue, and mucous membranes
5. Providing mouth care every 2 hours while the patient is awake
6. Seeking a dietary consult to increase fluids on meal trays
Ans: 1, 2, 4, 5
Rationale: The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessments. The patient should be reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than over the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider.
A patient has been diagnosed with disseminated herpes zoster. Which personal protective equipment will the nurse need to put on when preparing to assess the patient? Select all that apply.
1. Surgical face mask
2. N95 respirator
3. Gown
4. Gloves
5. Goggles
6. Shoe covers
2, 3, 4
Rationale: Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and do not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions.
Which patients must be assigned to an experienced RN? (Select all that apply.)
1. Patient who was in an automobile crash and sustained multiple injuries
2. Patient with chronic back pain related to a workplace injury
3. Patient who has returned from surgery and has a chest tube in place
4. Patient with abdominal cramps related to food poisoning
5. Patient with a severe headache of unknown origin
6. Patient with chest pain who has a history of arteriosclerosis
Patients with acute conditions that require close monitoring for complications should be assigned to an experienced RN. Abdominal cramps secondary to food poisoning is an acute condition; however, cramping, vomiting, and diarrhea are usually self-limiting. The patient with chronic back pain would be considered physically stable. Although all patients will benefit from care provided by an experienced RN, the patient with abdominal cramps and the patient with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse.
Patients 1, 3, 5, and 6 could have potential problems related to perfusion. The patient with the chest tube could also have a potential problem related to gas exchange.
For a patient who is receiving chemotherapy, which laboratory result is of particular importance?
1. White blood cell count (WBC): 3000/mm3 (3 × 109/L)
2. Serum potassium (K +): 3.4 mEq/L (3.4 mmol/L)
3. Prealbumin (PAB): 14 mg/dL (140 mg/L)
4. Blood urea nitrogen (BUN): 9 mg/dL (3.21 mmol/L)
1. White blood cell count (WBC): 3000/mm3 (3 × 109/L)
Rationale: Chemotherapy can decrease WBCs, particularly neutrophils (known as neutropenia). This leaves the patient vulnerable to infection. Normal range for WBC is 5000 to 10,000/mm3 (5-10 × 109 /L). The other tests are important in the total management but are less directly specific to chemotherapy. Normal range for K+ is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Low K+ could be associated with vomiting secondary to chemotherapy. Normal range for PAB is 15 to 36 mg/dL (150 to 360 mg/L); for BUN the range is 10 to 20 mg/dL (3.6 to 7.1 mmol/L); lower values for PAB or BUN could reflect malnutrition in a cancer patient.
A patient with newly diagnosed acquired immunodeficiency syndrome has a 6-mm induration at 48 hours after a skin test for tuberculosis (TB). Which action will the nurse anticipate taking next?
1. Arrange for a chest x-ray to check for active TB.
2. Tell the patient that the TB test results are negative.
3. Teach the patient about multidrug treatment for TB.
4. Schedule TB skin testing again in 12 months.
1. Arrange for a chest x-ray to check for active TB.
Rationale: According to the National Institutes of Health guidelines, an induration of 5 mm or greater indicates TB infection in patients with HIV and a chest radiograph will be needed to determine whether the patient has active or latent TB infection. Teaching about multidrug therapy is needed if the patient has active TB, but latent TB is treated with a single drug (usually isoniazid) only. Positive skin test results generally persist throughout the patient’s lifetime and will not be repeated, although other tests such as follow-up chest radiographs and sputum testing may be used to evaluate for effective TB treatment.
Which patient would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day?
1. A 68-year-old patient on a ventilator with acute respiratory failure and respiratory acidosis
2. A 72-year-old patient with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent
3. A newly admitted 56-year-old patient with diabetic ketoacidosis receiving an insulin drip
4. A 38-year-old patient on a ventilator with narcotic overdose and respiratory alkalosis
2. A 72-year-old patient with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent
Rationale: The patient with COPD, although ventilator dependent, is in the most stable condition of the patients in this group and should be assigned to the float nurse from the step-down unit. Patients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the patient with diabetic ketoacidosis is a new admission and requires an in-depth admission assessment. All three of these other patients need care from an experienced critical care nurse.
A pregnant patient in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important?
1. Arrange for testing for the Zika virus infection.
2. Discuss need for multiple fetal ultrasounds during pregnancy.
3. Describe potential impact of Zika infection on fetal development.
4. Assess for symptoms such as rash, joint pain, conjunctivitis, and fever.
1. Arrange for testing for the Zika virus infection.
Rationale: Current guidelines recommend that pregnant women who are exposed to Zika virus be tested for infection. Fetal ultrasonography is recommended for any pregnant woman who has had possible Zika virus exposure, but multiple ultrasound studies will not be needed unless test results are positive. Education about the effects of Zika infection on fetal development may be needed, but this is not the highest priority at this time. The nurse will assess for Zika symptoms, but testing for the virus will be done even if the patient is asymptomatic.
A patient’s opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?
1. Fever
2. Nausea
3. Diaphoresis
4. Abdominal cramps
3. Diaphoresis is one of the early signs that occurs between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal.
Which assessment finding is the most critical and needs to be addressed first?
1. A patient with small cell lung cancer has tracheal deviation after a pulmonary resection.
2. A patient with bladder cancer has decreased urination after intravesical chemotherapy.
3. A patient with non-Hodgkin lymphoma has cardiac dysrhythmias after chemotherapy
4. A patient has severe abdominal pain after a bowel resection for colon cancer
1. A patient with small cell lung cancer has tracheal deviation after a pulmonary resection.
Rationale: All of these conditions warrant calling the health care provider (HCP). Nevertheless, tracheal deviation is a symptom of tension pneumothorax, which is a medical emergency, and the nurse may have to intervene before the rapid response team or the HCP can arrive. Decreased urinary output for a patient with cancer is probably related to an obstruction, but other causes would be investigated. Dysrhythmias are one sign of tumor lysis syndrome secondary to hyperkalemia. After bowel resection, patients are at risk for hemorrhage or peritonitis.
An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20 mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question?
1. Discontinue prednisone after today’s dose.
2. Give a “catch-up” dose of varicella vaccine.
3. Check the patient’s C-reactive protein level.
4. Administer ibuprofen 800 mg PO TID.
2. Give a “catch-up” dose of varicella vaccine.
Rationale: The varicella (chicken pox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone. The other medical actions may need some further clarification by the nurse. Prednisone doses should be tapered gradually when patients have received long-term steroid therapy, but tapering is not usually necessary for short-term prednisone use. Measurement of C-reactive protein level is not the most specific test for monitoring treatment, but the test is inexpensive and frequently used. High doses of nonsteroidal anti-inflammatory drugs such as ibuprofen are more likely to cause side effects such as gastrointestinal bleeding but are useful in treating the joint pain associated with exacerbations of SLE.
The patient has an order for hydrochlorothiazide (HCTZ) 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? Select all that apply.
1. “Take this medication in the morning.”
2. “This medication should be taken in two divided doses: half when you get up and half when you go to bed.”
3. “Eat foods with extra sodium every day.”
4. “Inform your health care provider (HCP) if you notice weight gain or increased swelling.”
5. “You should expect your urine output to increase.”
6. “Your HCP may also prescribe a potassium supplement.”
1, 4, 5, 6
Rationale? HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the patient to wake up to urinate. This type of diuretic causes a loss of potassium, so the nurse should teach the patient about eating foods rich in potassium and should inform the patient that the HCP may prescribe a potassium supplement. Weight gain and increased edema should not occur while the patient is taking this drug, so these should be reported to the HCP.
The nurse manager is preparing for another community surge of Covid-19. Personal protective equipment (PPE) is in short supply at the hospital. Which methods are approved by the Center for Disease Control (CDC) for optimizing the supply of PPE during the surge? Select all that apply.
1. Wear a single pair of gloves between patients who have the same illness.
2. Disinfect gloves between patients to prevent cross contamination.
3. Wear the same N95 mask when in close contact with numerous patients.
4. Continuously wear the N95 mask between cohort patient encounters.
5. Use disposable patient isolation gowns for routine covid-19 patient care.
6. Use of cotton masks is acceptable if changed after every patient encounter.
1, 2, 4, 5
Rationale: The CDC has recommended all the above methods besides wearing an N95 mask between numerous patients and cotton masks. Disposable latex and nitrile gloves can be disinfected up to 6 times using alcohol based hand sanitizer. If N95 masks are unavailable then the recommendation is to utilize goggles, a surgical facemask and a facial shield. N95 masks should not be continuously worn for more than 8 hours and only between a cohort of covid-19 patients. Disposable isolation patient gowns are fluid resistant. Surgical gowns may be used as well but are sterile so they are not as cost efficient.
Which nursing action is the best example of the principle of nonmaleficence as an ethical consideration in pain management?
1. Patient seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication.
2. Patient has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine.
3. Patient is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the patient to verbalize personal goals for pain management.
4. Patient repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication.
1. Patient seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication.
Rationale: Nonmaleficence is to prevent harm. If the patient is excessively sedated, the nurse knows that giving additional opioid medication could do more harm than good, so the nurse would conduct further assessments and seek alternative options for pain relief. The patient’s report of pain should be believed, so based on the principle of justice, the nurse advocates for pain medication even though an organic cause of disease is not identified. By encouraging the patient to have a voice in his or her own pain management goals, the nurse is applying the principle of autonomy. By explaining the benefits of pain medication, the nurse is applying the principle of beneficence to help the patient recognize the balance between pain control and safety.
People at risk are the target populations for cancer screening programs. According to the latest screening recommendations from the American Cancer Society, which of these asymptomatic patients need extra encouragement to participate in cancer screening? Select all that apply.
1. A 25-year-old African-American woman who is sexually inactive, for a Pap test
2. A 30-year-old Asian-American woman, for an annual mammogram
3. A 45-year-old African-American man, to talk with the health care provider (HCP) about prostate cancer
4. A 55-year-old white American man who smokes, to talk with the HCP about a lung cancer screening
5. A 50-year-old white American woman, for colon cancer screening
6. A 70-year-old Asian-American woman who had a total hysterectomy 15 years ago (not for cancer reasons), for a Pap test
Ans: 1, 3, 4, 5
Rationale: At 25 years of age, women should have a Pap smear, regardless of sexual activity. Annual mammograms are recommended for women with average risk starting at age 45. African-American men with average risk starting at age 45 years should talk to their HCPs about prostate cancer and risk versus benefits of prostate-specific antigen testing. Men aged 55 years or older who smoke should be advised to talk to their provider about lung cancer screening. Colon cancer screening tests are recommended for those with average risk starting at age 45 years. Women who have had a total hysterectomy for reasons other than cancer do not need a Pap test.
A patient who has human immunodeficiency virus and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider?
1. The patient exclaims, “I’m afraid I’m going to die right here!”
2. The prescribed patient medications include midazolam 2 mg IV immediately.
3. The patient is diaphoretic and tremulous and reports dizziness.
4. The symptoms occurred suddenly while the patient was driving to work.
2. The prescribed patient medications include midazolam 2 mg IV immediately.
Rationale: Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications. Midazolam should not be given to this patient. The other patient data are consistent with the patient’s diagnosis of panic attack and do not indicate an urgent need to communicate with the provider.
The nurse is completing a history for an older patient at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply.
1. “Which drugs do you take on a daily basis?”
2. “Do you have any problems with breathing?”
3. “When was your last bowel movement?”
4. “Have you experienced any activity intolerance or fatigue in the past 24 hours?”
5. “Over the past month have you had any dizziness or tinnitus?”
6. “Do you have episodes of drowsiness or decreased alertness?”
1, 2, 4, 6
Rationale: Collect data about risk factors related to the development of acidosis. Older adults may be taking drugs that disrupt acid-base balance, especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes, increased drowsiness, reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and increased fatigue. Ask the patient to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3 and 5 are not common concerns with acidosis.
The nurse is supervising an LPN/LVN who says, “I gave the patient with myasthenia gravis 90 mg of neostigmine instead of the ordered 45 mg!” In which order should the nurse perform the following actions?
1. Assess the patient’s heart rate.
2. Complete a medication error report.
3. Ask the LPN/LVN to explain how the error occurred.
4. Notify the health care provider of the incorrect medication dose.
1, 4, 3, 2
Rationale: The first action after a medication error should be to assess the patient for adverse outcomes. The nurse should evaluate this patient for symptoms such as bradycardia and excessive salivation, which indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The health care provider should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report.