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) Respiratory rate: 10 breaths/min.This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.

Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.

The normal respiratory rate for adults is 12 to 20 breaths/min.

Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg.Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.

Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min.Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.

Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans.Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.

A. “I will change the patch every other day.” B. “I will apply the patch to a hairy area for better adhesion.” C. “I will remove the old patch before applying a new one.” D. “I will cut the patch in half if I need a lower dose.”.

Correct Answer is C

Explanation

The correct answer is choice C.The patient should remove the old patch before applying a new one to avoid overdose and adverse effects of fentanyl.Fentanyl patches are designed to deliver a constant amount of opioid analgesic over a period of time, usually 72 hours.

Therefore, changing the patch every other day (choice A) would result in inadequate pain relief and withdrawal symptoms.

Applying the patch to a hairy area (choice B) would interfere with the absorption of the drug and reduce its effectiveness.

Cutting the patch in half (choice D) would damage the integrity of the patch and cause erratic or rapid release of the drug, which could be fatal.Fentanyl patches should be applied to a clean, dry, hairless area of intact skin on the upper torso or upper arm.

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

Correct Answer is A

Explanation

A nurse is caring for a patient who has been prescribed fentanyl patches for chronic cancer pain management at home. Which statement by the patient indicates that he understands how to use this medication safely?

Correct Answer is C

Explanation

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A nurse is educating a patient who has been prescribed aspirin for the prevention of cardiovascular events. Which of the following instructions should the nurse include? (Select all that apply.)

A nurse is teaching a client who has chronic pain about nonpharmacological pain management techniques. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

A nurse is caring for a client who has rheumatoid arthritis and has been prescribed ibuprofen (Advil). Which of the following instructions should the nurse include in the teaching? Select all that apply.

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

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.