The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.

Use a standard pain assessment tool

Increase features of the scale, such as font size

Repeat instructions and questions more than once D. Ask about present level of pain rather than pain history

Ask about present level of pain rather than pain history

Allow ample time for the patient to respond (Source: https://quizlet.com/129952120/pain-assessment-hesi-flash-cards/).

Answer and Explanation

Correct Answer : A,B,C,E

The correct answer is choice A, B, C and E. These actions by the nurse help facilitate the pain assessment by using a consistent and clear method to measure the patient’s pain level, enhancing the visibility and understanding of the scale, repeating the information for clarity and accuracy, and giving the patient enough time to respond without rushing or interrupting.

Choice D is wrong because asking about the present level of pain rather than the pain history is more relevant for pain management, not the pain assessment. The pain history provides valuable information about the onset, duration, frequency, quality, intensity, location, and aggravating or relieving factors of the pain.

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Correct Answer is A

Explanation

The correct answer is choice A. The client reports a pain level of 4 on a scale of 0 to 10.This indicates that the PCA pump is effective in reducing the client’s pain, which is the primary symptom of sickle cell crisis.

Choice B is wrong because a respiratory rate of 12 breaths per minute is normal and does not indicate the effectiveness of the PCA pump.

Choice C is wrong because a blood pressure of 140/90 mm Hg is high and may indicate hypertension, which is a complication of sickle cell disease.

Choice D is wrong because a pulse oximetry reading of 95% is normal and does not indicate the effectiveness of the PCA pump.

Normal ranges for vital signs are:

• Respiratory rate: 12-20 breaths per minute

• Blood pressure: <120/80 mm Hg

• Pulse oximetry: >95%

A. “I should drink plenty of fluids and eat high-fiber foods to prevent constipation.” B. “I should avoid driving or operating heavy machinery while taking this medication.” C. “I should take this medication only when I have severe pain that does not respond to other drugs.” D. “I should report any signs of an allergic reaction, such as rash, itching, or difficulty breathing.”.

Correct Answer is C

Explanation

The correct answer is choice C.The client should take this medicationregularlyas prescribed to maintain a steady level of analgesia and prevent breakthrough pain.

Taking the medication only when the pain is severe can lead to inadequate pain relief and increased side effects.

Choice A is wrong because drinking plenty of fluids and eating high-fiber foods can help prevent constipation, which is a common adverse effect of opioids.

Choice B is wrong because avoiding driving or operating heavy machinery is a safety precaution for clients taking opioids, as they can cause drowsiness and impaired judgment.

Choice D is wrong because reporting any signs of allergic reaction is an important instruction for clients taking any medication, especially opioids, which can cause severe hypersensitivity reactions.

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The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a sickle cell crisis and is receiving morphine via patient-controlled analgesia (PCA) pump. Which assessment finding indicates that the PCA pump is effective?

Correct Answer is A

Explanation

A nurse is teaching a client who has cancer pain about the use of oral oxycodone with acetaminophen (Percocet). Which statement by the client indicates a need for further teaching?

Correct Answer is C

Explanation

A nurse is caring for a patient who is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?

A nurse is providing discharge teaching to a client who has a prescription for acetaminophen and hydrocodone (Vicodin).Which of the following instructions should the nurse include in the teaching?

A client with osteoarthritis has been prescribed celecoxib (Celebrex). The nurse should instruct the client to report which of the following adverse effects immediately?

A nurse is administering naloxone to a patient who has overdosed on heroin. What is the expected outcome of this intervention?

Which component of pain assessment is addressed by asking a client to rate his or her current level of discomfort on a scale of 0-10?

A patient who is addicted to heroin is admitted to the hospital for treatment of an infection. The patient is prescribed methadone (Dolophine) as part of a detoxification program. What is the rationale for using methadone in this patient?

The nurse is preparing to administer morphine sulfate, an opioid analgesic, to a client who reports pain at level 8 on a scale of 0 to 10. Which action should the nurse take first?

A patient who has chronic low back pain is prescribed oxycodone (OxyContin) for long-term use. Which of the following interventions should the nurse implement to prevent complications from this medication? (Select all that apply.)