Chapter 15: Pain Management

Multiple Choice

1. The nurse teaches the patient progressive self-relaxation techniques. Which would the nurse implement first?

a. Direct the patient to envision sailing on a sailboat.

b. Instruct the patient to increase respiratory rate and depth.

c. Establish the patient’s ability to participate and cooperate.

d. Darken the patient’s room significantly and close the door.

ANS: C

The nurse begins by assessing the patient’s ability to participate and cooperate to tailor the teaching techniques and vocabulary to him or her. This increases the likelihood of the patient benefiting from the instruction. Envisioning pleasant things is part of teaching guided imagery but is not the initial step. After assessing the patient, the nurse provides a brief overview of the technique and sets a proper learning environment. Deep respirations are an indication of relaxation; however, instructing a patient to take deep breaths would not precede assessing the patient’s ability to cooperate.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Use the friction technique over the spine. b. Assess for pain, anxiety, and discomfort. c. Instruct the patient to sit upright and forward. d. Knead the patient’s scalp with warm lotion.

2. The nurse massages the patient to promote relaxation. Which is a suitable intervention for the nurse to implement during the massage?

ANS: B

The nurse’s goal during a massage is to keep the patient comfortable and relaxed and induce a lingering sense of well-being and relaxation at the completion of the massage. If the patient is in pain, anxious, or uncomfortable, relaxation does not occur until the noxious stimuli are eliminated. The nurse asks the patient about pain and comfort during the massage and does not wait for the patient to offer such statements. The friction technique (i.e., strong, circular strokes enhancing perfusion at the skin’s surface) is contraindicated for bony prominences such as the spine because the regional skin is already thin and under tension by nature of its location over a bone. Sitting upright and forward can be contraindicated or uncomfortable for the patient. Occasionally the patient’s scalp is massaged with a few drops of oil on the fingertips; it is impossible to knead the scalp because the scalp is devoid of large, thick muscles.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Encourage controlled breathing. b. Provide a glass of warm milk at bedtime. c. Give a sedative 1 hour before sleep. d. Increase fluids and reposition the patient.

3. The patient has hypotension, receives as much opioid analgesia as the prescription allows, and continues to have difficulty sleeping at night because of pain. Which should the nurse implement to relieve pain and improve sleep?

ANS: A

When adequate pain relief is not obtained via pharmacological means, the nurse offers nonpharmacological, alternative therapies. Controlled breathing is one way to promote relaxation and enhance pain control. Warm milk may be helpful to some patients, however; it is not known that the patient is allowed milk or can tolerate it. A sedative would not be an appropriate choice because the patient is already hypotensive. Increasing fluids will probably cause the patient to need to use the bathroom which will further interfere with sleep.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Spinal cord injury b. Hypertension c. Acute asthma d. Crohn’s disease

4. The nurse wants to use massage to promote relaxation. In which patient diagnosis would massage be potentially contraindicated?

ANS: A

Massage may be contraindicated after spinal cord injuries or surgery to head and neck because of risk of further injury. Patients with hypertension, acute asthma, and Crohn’s disease potentially benefit from a massage as relaxation therapy.

N

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Dispense the opioid 30 minutes after providing food. b. Combine the opioid with a sedative or an antihistamine. c. Collaborate with the provider about antiemetic drug therapy. d. Replace the analgesic with a nonsteroidal antiinflammatory agent.

5. The patient with metastatic bone pain from cancer reports nausea and vomiting after receiving periodic opioid analgesia intravenously. Which can the nurse implement to manage the patient’s pain effectively without nausea and vomiting?

ANS: C

Nausea is a frequent side effect of opioid treatment. Fortunately, it is easily treated with antiemetics. The nurse would collaborate with the provider to obtain this medication for the patient. Giving opioids with food is a good idea for oral medications. The patient does not need a sedative or antihistamine. For metastatic bone pain, a NSAID will not provide adequate relief.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The patient has not had a bowel movement since surgery. b. The patient declines a massage after analgesic administration. c. Respiratory rate drops from 22 to 16 breaths/min. d. The patient receives famotidine for esophageal reflux.

6. The patient receives opioid analgesia along with naproxen after a total abdominal hysterectomy. Which patient information leads the nurse to collaborate with the provider about this prescription?

ANS: D

A patient history of esophageal reflux is usually a contraindication for nonsteroidal antiinflammatory drug (NSAID) administration because of the increased risk of bleeding from prostaglandin inhibition. Constipation is a complication of surgery and opioid analgesia, but the nurse manages patient constipation by increasing patient ambulation and intake of fiber, fluid, and stool softeners. Declining a massage after receiving pain medication potentially indicates that the patient is satisfied with her comfort and relaxation status. Respirations at 16 breaths/min are within normal limits.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Fill a glass with water. b. Record the administration time. c. Check the medication dose. d. Help the patient to sit upright.

7. The nurse prepares an oral opioid analgesic for the patient who has dementia and pain. After checking the patient’s medication administration record (MAR) for the last administration time and the patient’s response to pain medication, the nurse chooses the correct analgesic and compares the patient’s picture and wristband to the medical record. Which is the most important intervention for the nurse to implement next?

ANS: C

The most important intervention at this point is to check the MAR and verify the correct dose before administration to prevent adverse effects and toxicity. This is important from a safety standpoint and follows the rights of medication preparation and administration. The nurse would ensure the patient has adequate water to drink prior to giving the pill. Assisting the patient to a particular position may be required, but it is not the most important intervention now. The nurse should be focused on safety during the preparation and administration of medication. Medication documentation occurs after the medication is administered.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Older adults have higher risks of injury with intramuscular (IM) injections. b. Analgesics aren’t necessary for older adults because of decreased pain sensation. c. Impaired cognition impairs reporting of pain by older patients. d. Liver and kidney metabolism is usually slower in older adults.

8. The nurse decides that collaboration with the health care provider is needed to review and possibly adjust the dose of analgesic for an 87-year-old patient. What is the most likely rationale for this request?

ANS: D

As the adult ages, hepatic and renal clearance of medication usually decreases or slows, so medication has a longer duration of action, and doses exert a stronger effect than in younger people. The nurse helps to maintain patient safety and prevent injury by collaborating to adjust the dose of the analgesic. Risk of injury from an IM injection refers to the route of administration and is not dependent on the dose. Nothing in the question indicates that an IM injection is the mode of administration. The nurse uses the patient’s self-report of pain felt to help determine the need for pain relief; reporting pain refers to patient assessment. This option does not address the reason for adjusting the dosage.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Check the volume of morphine in the PCA syringe. b. Check the frequency of patient-controlled dosing. c. Collaborate with the provider to increase basal rate. d. Check the PCA pump for malfunction.

9. The adult patient who receives morphine sulfate intravenously by patient-controlled analgesia (PCA) tells the nurse that the pain level is 8 on a scale of 0–10. Which is the best intervention for the nurse?

ANS: B

The PCA dose includes a basal rate to establish and maintain a therapeutic morphine serum level and a supplemental dose of morphine, the patient-controlled dose, for patient pain management. The nurse checks the frequency of patient self-dosing to gather additional information for a nursing assessment. If the patient is not supplementing the basal dose, the nurse instructs the patient to use the patient-controlled dose by directing the patient to depress the PCA button for pain control. The nurse allows 30 minutes to 1 hour to evaluate the plan. If the patient is using the PCA properly, the patient may benefit from an increased basal rate. If the patient is depressing the PCA button, the syringe of morphine may be empty; however, the PCA has an alarm to indicate low volume, and the nurse monitors the volume for narcotic control and intake and output (I&O), so it is unlikely that an empty syringe will be the problem. Collaborating with the provider to increase the PCA dose is premature because the nurse has not completed an assessment or implemented nursing interventions that potentially resolve the patient’s pain. It is reasonable to check the pump for malfunction after checking the patient-controlled dosing.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. A patient after a bowel resection for recurrent colon cancer b. A patient after an internal fixation of an ankle fracture c. A first-time hospitalized patient after amputation of a leg d. A patient with emphysema who had a lung tumor resection

10. The nurse cares for several postoperative patients using patient-controlled analgesia (PCA) pain management with a combination of an opioid and a local anesthetic agent on the first postoperative day. Which patient will the nurse assess first?

ANS: C

The nurse assesses the patient with the amputation first. Since this is the patient’s first hospitalization, it is unknown how he or she will react to the pain medications, and they can cause respiratory depression, especially in an opioid-naïve patient. The patient with chronic obstructive pulmonary disease (COPD) is probably the second patient the nurse assesses because the disease is pulmonary. If the patient hypoventilates because the pain is too great, he or she is likely to retain additional carbon dioxide, inadequately oxygenate, and potentially have respiratory acidosis and respiratory failure. The other patients would be assessed as soon as possible.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Patient is hypoventilating. b. Pain level ranges from 2 to 4. c. Sedation level is consistent. d. RR is 26 breaths/minute.

11. The nurse assesses the patient who is 2 days postoperative to determine the need for continuing patient-controlled analgesia (PCA). Which information does the nurse use to decide that the patient is ready for oral administration of analgesia?

ANS: B

The nurse uses the patient’s pain level ranging from 2 to 4 to help determine that oral analgesia is suitable for him or her because the patient’s pain level is consistently below the mid-range on the pain scale. PCA is more suitable for moderate-to-severe pain, and oral analgesia is more suitable for low-to-moderate pain. Hypoventilation is an adverse effect of opioid analgesia, regardless of the administration method. A consistent sedation level is vague and provides little information about patient status. It can indicate a serious neurological impairment or excessive dosing and warrants further investigation. An elevated respiratory rate can be a nonverbal indicator of pain and inadequate pain relief. However, this respiratory rate alone gives no indication of the best route for administration of analgesia.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Elevates the head of the bed (HOB) to 30 degrees. b. Increases the interval between demand doses. c. Increases the demand and the basal doses. d. Checks patient manipulation of the PCA button.

12. The patient who receives patient-controlled analgesia (PCA) with an opioid analgesic reports that the pain level is 9 on a scale of 0–10. Which action does the nurse take first?

ANS: D

The nurse checks to ensure that the patient understands and executes depression of the PCA button for on-demand doses. If the patient does not operate the button or does so ineffectively, he or she receives inadequate pain control. The nurse can elevate the HOB if the patient is oversedated and difficult to arouse unless it is contraindicated. By elevating the HOB, the nurse repositions and enables the patient to receive more environmental stimulation. The patient receives less medication when the time between demand doses is increased. The nurse avoids increasing the basal rate and demand dose simultaneously to prevent oversedation because increasing each rate of administration increases the total potential dose twice.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The catheter tubing does not have a filter needle. b. The distal end of the tubing is attached to the catheter. c. The infusion contains an opioid and a local anesthetic. d. The pump settings match the provider prescription.

13. The nurse and a student nurse receive a patient in the post anesthesia recovery unit and assesses the epidural analgesic infusion. Which assessment finding by the student is the nurse’s priority?

ANS: A

The tubing needs a filter needle to prevent bacteria from entering the infusion line. If the student reports that there is no filter present, this would be the priority for the nurse to address. The other assessment findings are expected.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Reassure the patient that some numbness is expected. b. Assess the entire patient before continuing the treatment. c. Remove the compress and assess the affected area. d. Provide a warm blanket for the patient’s treatment.

14. The patient reports slight burning-like pain and numbness on the skin under a cold compress. Which action by the nurse is most appropriate?

ANS: C

Burning pain and numbness indicate a possible complication from the cold therapy, so the nurse stops the treatment immediately and assess the site prior to notifying the provider. The nurse would not just reassure the patient without assessing the problem. The nurse conducts a focused assessment; the patient does not need a head-to-toe assessment. The patient may or may not want or need a warm blanket, but this does not address the possibility of complications.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Leave the ice on for no more than 5 minutes. b. Remove the ice pack when the ice melts completely. c. A cold pack has the potential to cause tissue damage. d. Apply ice for an hour and then apply a heating pad.

15. The nurse teaches the patient in ambulatory care to apply ice packs to an injured knee. What instructions does the nurse include in patient teaching?

ANS: C

The nurse explains that prolonged application of ice can lead to tissue damage from prolonged vasoconstriction. The patient should be instructed to apply the ice for 10–20 minutes, then remove the ice for 30 minutes and check affected tissue before repeating the cycle to prevent tissue damage. Applying ice for 5-minute increments is subtherapeutic treatment. The nurse avoids teaching the patient to leave the ice in place until it melts because it is likely to result in ice application exceeding 20 minutes and increase the risk for tissue damage. Application of ice for 1 hour exceeds the 20-minute recommendation to prevent tissue damage.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. A cold compress b. A covered ice bag c. An aquathermia pad d. A moist heat compress

16. The school nurse provides first aid to the 10-year-old student with a new uncomplicated arm fracture. The nurse wants to provide nonpharmacological pain relief and minimize regional edema. Which first-aid treatment does the nurse provide for the patient?

ANS: B

The nurse applies an ice bag with a cover between it and the student’s arm to reduce pain, swelling, and bleeding because cold therapy provides a regional anesthetic effect and vasoconstricts to limit regional blood flow. A cold compress is inadequate to provide regional vasoconstriction for a fractured arm. Heat application from an aquathermia pad or a moist compress is contraindicated for the fracture because both therapies increase blood flow and promote vasodilation. The fluid pressure in the area can increase from the heat to increase patient pain, bleeding, and edema.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Osteoarthritis b. Nephrolithiasis c. Chronic bronchitis d. Peripheral neuropathy

17. The nurse plans care for four patients receiving heat therapy. Which patient will the nurse consult with the provider about this order?

ANS: D

The patient admitted for a peripheral neuropathy has the highest risk for a heat therapy injury because he or she has impaired sensation to the extremities, meaning that the patient has difficulty sensing pain, heat, and pressure. This patient is more likely to incur tissue damage from heat therapy because he or she has impaired ability to sense excessive heat. The nurse would consult the provider to determine other therapies for this patient’s pain. The patient with osteoarthritis can have a slightly higher risk of thermal injury from heat therapy if patient mobility is impaired because a self-protective mechanism is withdrawal from noxious sensations such as excessive heat. Patients with nephrolithiasis, kidney stones, and chronic bronchitis can be suitable candidates for heat therapy because these diagnoses are unrelated to peripheral perfusion, sensation, or movement.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Check the patient’s pulse rate. b. Dry off the patient completely. c. Ask the patient if he or she is able to ambulate. d. State that dizziness is common.

18. The nursing assistive personnel (NAP) reports that the patient is dizzy during a warm sitz bath. Before moving the patient, what action by the nurse is the priority?

ANS: A

The nurse should assess the patient’s pulse rate to determine if the patient is stable enough to either continue the bath or ambulate back to bed with assistance. Unless a sphygmomanometer is readily available, taking the pulse is a good clinical indicator to evaluate hypotension indirectly because when the blood pressure falls, the heart rate increases to maintain the cardiac output. Dizziness is a common response to a warm bath for patients who are older or who have cardiovascular, neurovascular, or chronic pulmonary conditions, but the nurse needs to assess the patient before deciding what is happening. The patient will need to be dried off and the nurse can ask the patient if he or she is able to walk, but an objective assessment is better.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Decreased pain and diaphoresis b. Decreased bleeding and vasoconstriction c. Vasodilation and decreased blood flow d. Increased oxygenation and increased inflammation

19. In the postanesthesia care unit the nurse applies an ice bag to the patient’s leg at the surgical site. Which therapeutic effect does the nurse expect from this treatment?

ANS: B

The nurse applies cold therapy to the patient’s surgical site for regional vasoconstriction, which also decreases bleeding. Diaphoresis commonly occurs with dry heat therapy, but decreased pain can occur with cold or heat therapy, depending on the type of injury. Cold therapy causes vasoconstriction, not vasodilation, and blood flow is decreased as a result of vasoconstriction.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Place the gel pack on the ankle for 30 minutes every 4 hours. b. Wrap the ankle with a lightweight cloth before applying the ice bag to it. c. Wrap the elastic bandage firmly before applying the ice to the ankle. d. Immerse the foot in a pan of ice water every 2–4 hours.

20. The patient received treatment for a sprained ankle and is receiving home care instructions regarding cold therapy. Which instructions does the nurse include?

ANS: B

The patient needs to prevent direct exposure of the skin to the ice bag. The gel pack must be wrapped before being put against the ankle. The elastic bandage can interfere with circulation if wrapped too tightly, and the wrap itself can prevent the cold from being effective. Immersion would require the patient to place his foot in a dependent position, which can increase swelling.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Multiple Response

1. The nurse assesses the patient and realizes that patient pain is interfering with postoperative therapies. Which assessment findings indicate the patient may be a candidate for nonpharmacological interventions? (Select all that apply.)

a. The patient has used guided imagery in the past successfully.

b. Nonpharmacological relaxation methods appeal to the patient.

c. The provider plans to discharge the patient to home in 2 days.

d. The patient understands written information on relaxation techniques.

e. The patient cannot receive additional analgesia for unresolved pain.

ANS: A, B, E

An integrated approach using pharmacological and nonpharmacological therapies is the most effective method of pain management. Patients who potentially benefit the most from integrated therapies share certain qualities, including successful use of nonpharmacological therapies in the past and a willingness to try alternative and/or complementary therapies. A patient who cannot receive additional pain medication despite continuing pain is likely to benefit from integrated therapy as well. The discharge date is unrelated to assessing the patient before relaxation and guided imagery. The nurse can explain and demonstrate relaxation therapies and guided imagery without the patient reading.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Facial grimacing during linen changes b. Eats a full liquid diet without assistance c. Uses the incentive spirometer every hour d. Patient’s culture forbids complaints of pain e. Has received nothing for pain since surgery f. Heart rate 110, blood pressure 169/90

2. The nurse caring for a patient 1 day after a thoracotomy assesses that the patient is in pain, but the patient denies having pain. Which does the nurse use to confirm the patient’s pain? (Select all that apply.)

ANS: A, D, E, F

To confirm the pain assessment for a patient who states that she has no pain, the nurse looks for information consistent with a patient in pain. The patient’s verbal message and nonverbal cues are contradictory because facial grimacing is a hallmark sign of pain and discomfort, especially when the patient moves. A potential explanation for the inconsistent verbal and nonverbal messages is that the patient’s culture forbids admitting to pain, necessitating the use of other pain indicators. The lack of prior pain medication would indicate no trials of pain control at all. Tachycardia and hypertension can be good clinical indicators of pain when the patient expresses contradictory messages about pain; however, do not rely on vital sign measurements alone. Eating and breathing deeply are inconsistent with a patient in pain.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Temperature 38.1° C (100.6° F) b. Patient ready for oral analgesia c. Low tension on epidural catheter d. Respiratory rate 14, sedation level 1 e. Epidural drainage looks like clear medication f. Hemoglobin 15 mg/dL, leukocytes 14,500

3. The nurse assesses a patient who has an epidural catheter for patient-controlled analgesia (PCA) on the second postoperative day. Which patient data does the nurse group together to establish the nurse’s priority? (Select all that apply.)

ANS: A, E, F

According to the nursing process, the nurse groups interrelated data together to draw a conclusion. This patient is febrile with leukocytosis and clear epidural drainage, clinical indicators of a potential infection. Because fluid is leaking from the insertion site, microorganisms have a potential portal of entry, even though the fluid is of unknown origin. The nurse collaborates with the provider to discontinue the epidural catheter, initiate therapy to eradicate potential infection, and provide adequate pain management by another route. If the fluid is cerebrospinal fluid (CSF), the patient is at risk for a devastating neurological infection and sepsis. Patient readiness for oral analgesia is not as important to patient health and well-being as dealing with the potential infection. Low tension on the catheter, a respiratory rate within normal limits, and a low sedation level are desirable patient data. They are not disregarded by the nurse in formulating nursing care but are less important than a potential infection. The nurse plans nursing care to enhance positive patient assessments to promote health and well-being.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Diagnosis a. Consider patient cognitive level. b. Evaluate patient communication. c. Confirm two separate intravenous (IV) infusions. d. Determine patient physical ability. e. Assess for history of constipation. f. Verify patient medication allergies.

4. The nurse prepares patient-controlled analgesia (PCA) for a postoperative patient in the post anesthesia recovery unit (PACU). To rule out contraindications to therapy, which should the nurse assess before the patient receives PCA? (Select all that apply.)

ANS: A, B, D, F

The nurse assesses the patient’s cognitive level to verify suitability of PCA for pain management. If the patient cannot understand instructions, PCA will have little value to the patient in managing pain. The nurse evaluates communication to ensure patient ability to relate pain levels effectively; if the patient does not speak English or is cognitively impaired, the nurse establishes a method of nonverbal communication to determine pain level and effectiveness of therapy. The nurse ensures the patient’s physical ability to depress the PCA button. He or she checks patient allergies to medication before initiating PCA to prevent hypersensitivity reactions. One IV infusion is sufficient for PCA if the infusion is continuous or only infuses the PCA. If PCA is infused through the same tubing as intermittent infusions, the nurse risks bolus administration of the opioid and possibly the local anesthetic agent; this increases the risk of respiratory depression. Constipation does not contraindicate the use of PCA.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning