Question 1

The patient had knee replacement surgery and has a local infusion pump to provide a local anesthetic to the surgical site.The patient puts on the call light and complains that pain at the site is more intense than it has ever been and is getting worse.The nurse checks the site and finds that the dressing is damp but intact.The infusion pump is pumping, and there is medication in the bag.The most probable cause of the problem might be the:

Accepted Answer

Assess the surgical dressing and the site of catheter insertion.The dressing should be dry and intact.Determine whether the catheter is properly placed.If the catheter is clogged, infusion of medication will stop.Pain levels will increase but the dressing will be dry, and the pump should alarm.If the pump is releasing too much medication, the nurse should expect to see symptoms of local anesthetic adverse reaction.It is not the patient's responsibility to convince the nurse that he has pain; it is the nurse's responsibility to believe the patient.

Question 2

A nurse is evaluating the epidural catheter insertion site and suspects that the intraspinal catheter has punctured the dura when _____ noted.

Accepted Answer

Clear drainage may indicate puncture of the dura.Bloody drainage may indicate that the catheter has entered the blood vessel.Purulent drainage is a sign of infection.Redness, warmth, and swelling are signs of inflammation.Local inflammation and superficial skin infection can occur at the insertion site.

Question 3

The nurse caring for a patient who has a PCA knows that it:

Accepted Answer

PCA allows more constant serum levels of the opioid, and, as a result, it avoids the peaks and troughs of a large bolus.Because the blood level is maintained within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased.Potential concerns involving PCA use are pump failure, and operator errors.Patients may misunderstand how PCA therapy works, may mistake the PCA button for the nurse call button, or may have family members who operate the demand button.Instruct the family not to push the timing device for the patient unless the patient is unable to push the button himself, and the nurse has instructed the family to do so.Use of a PCA pump does not prevent mistakes.The pump may fail to deliver drug on demand, may have a faulty alarm or a low battery, or may lack free-flow protection.Operators may incorrectly program the dose, concentration, or rate.Not all patients are candidates for PCA.Assess the patient's cognitive ability to determine the appropriateness of PCA pain management.

Question 4

A nonpharmacological approach that the nurse may implement for patients who are experiencing pain that focuses on diverting the patient's attention away from the pain sensation by promoting pleasurable and meaningful stimuli is:

Accepted Answer

Distraction is a technique that diverts an individual's attention away from the pain sensation.By introducing meaningful stimuli, the nurse helps the patient refocus attention.Distraction directs a patient's attention to something else and thus can reduce awareness of pain and even increase tolerance.A proper massage not only blocks the perception of pain impulses but also helps relax muscle tension and spasm that otherwise might increase pain.Massage hastens the elimination of wastes stored in muscles, improves oxygenation of tissues, and stimulates the relaxation response in the nervous system.Heat produces vasodilation, reduced blood viscosity, reduced muscle tension, and increased tissue metabolism.Heat helps relieve muscle spasms and joint stiffness.Cold produces vasoconstriction, reduced cell metabolism, and increased blood viscosity.Cold is effective for inflamed joints and muscles.The goal of imagery is to have the patient use one or several of the senses to create an image of the desired result.This image creates a positive psychophysiological response.Guided imagery can be used as a distraction technique.

Question 5

The nurse is caring for a patient who is a devout Orthodox Jew.The patient is on a patient-controlled analgesia ( PCA ) pump.What accommodations might the nurse have to make to conform to the patient's cultural needs?

Accepted Answer

Orthodox or Observant Jews may not use electrical equipment during the Sabbath and on Holy Days; therefore, the staff should program the PCA to achieve optimum pain relief.Alternative methods will be needed during these times.Cultures vary regarding when to recognize pain, what words to use in expressing pain, when to seek treatment, and what treatments are desirable.Russians, Asians, and Native Americans tend to be stoic, whereas Italians, Puerto Ricans, and Jews tend to be more expressive.The nurse should ask the patient about his preferences.Some Hindu patients believe that suffering is a consequence of actions in a previous life.For example, a belief in the concept of Karma motivates the patient to bear the pain, refuse pain medications, and suffer in silence.Some Jews view pain as a communal suffering that they should share with others to affirm their life experience.

Question 6

The nurse who is caring for a patient postoperatively notes that he is expressing discomfort and is diaphoretic.Which of the following interventions is most appropriate?

Accepted Answer

Administer pain-relieving medications as ordered.Analgesics are the cornerstone of pain management.Smoothing wrinkles in bed linens may reduce pressure and irritation to the skin; however, pain-relieving medication should be given first.Changing a wet surgical dressing might not be needed if the patient has received a wet-to-dry dressing as treatment, or if not changing the dressing will reduce irritation to the skin but will not address the discomfort.Reposition underlying tubes, wires, or equipment that may apply pressure directly to dependent skin surfaces.Removing these stimuli may maximize the response to pain-relieving interventions such as medication, but pain-relieving medication should be administered first.

Question 7

The nurse is preparing to administer a bolus of epidural medication.The nurse must remember to:

Accepted Answer

Clean the injection cap of the epidural catheter with povidone-iodine, or substitute anti-infective according to agency policy.Alcohol causes pain and is toxic to neural tissue.Inject opioid at a rate of 1 mL over 30 seconds.Slow injection prevents discomfort by lowering the pressure exerted by fluid as it enters the epidural space.The catheter is in a space, not a blood vessel; thus flushing with saline is not required.

Question 8

The patient's family is concerned that the patient may get too much pain medication after surgery and become addicted to the medication if he is placed on a PCA pump.They also voice concern about the effectiveness of the PCA.The nurse should instruct the family and the patient that:

Accepted Answer

Because the device provides medication on demand as soon as the patient feels the need, the total amount of opioid use is reduced.Because the blood level stays within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased.The PCA has several advantages.It allows more constant serum levels of the opioid and, as a result, avoids the peaks and troughs of a large bolus.An advantage of PCA is that when used postoperatively, fewer complications arise because earlier and easier ambulation occurs as a result of effective pain relief.

Question 9

While reviewing a patient's medication history, the nurse determines that intraspinal analgesia is contraindicated as a result of:

Accepted Answer

Recent anticoagulants sometimes contraindicate the placement of an epidural catheter because of the risk for epidural hematoma at the insertion site.Certain conditions may make epidural analgesia the method of choice for pain control: following surgery, for patients with trauma or advanced cancer that is not responsive to other pain management modalities, and those predisposed to cardiopulmonary complications because of a preexisting medical condition or surgery.Previous spinal anesthesia is not a contraindication for receiving subsequent spinal anesthesia.

Question 10

The nurse frequently must assess a patient who is experiencing pain.When assessing the intensity of the pain, the nurse should:

Accepted Answer

Descriptive scales are an objective means of measuring pain intensity.Use a pain intensity scale appropriate to the patient's age, developmental level, and comprehension, and ask the patient to rate the pain.An appropriate pain rating scale is reliable, easily understood, and easy to use, and it reflects changes in pain intensity.Asking the patient what precipitates the pain does not assess intensity, but rather assesses the pain pattern.Asking the patient about the location of pain does not assess the intensity of the patient's pain.To determine the quality of the patient's pain, the nurse may ask open-ended questions to find out about the sensation experienced (e.g., "Tell me what your pain feels like").This approach assists in identifying the underlying pain mechanism (e.g., somatic or neuropathic pain), but it may not reveal intensity or changes in intensity.

Question 11

The nurse knows that an advantage of intraspinal analgesia is the:

Accepted Answer

Because opioids are delivered close to their site of action, the central nervous system (CNS), they have greater bioavailability and thus require much smaller doses to achieve adequate pain relief.Epidural and intrathecal doses are not equivalent.Intrathecal doses are much smaller than epidural doses.As an example, the epidural dose of morphine is 10 to 20 times greater than that required for an intrathecal dose.The catheter poses a threat to patient safety because of its anatomical location, its potential for migration through the dura, and its proximity to spinal nerves and vessels.Migration of an epidural catheter into the subarachnoid space can produce medication levels too high for intrathecal use.Fentanyl and sufentanil are hydrolipid, which causes them to have a quicker onset and a shorter duration of action (2 hours).Morphine and hydromorphone are hydrophilic, resulting in a longer onset and a longer duration of action (up to 24 hours with a single bolus dose).

Question 12

When evaluating the effects of PCA, the nurse notes that the patient is sedated and is difficult to arouse.What step should the nurse take next?

Accepted Answer

If the patient is sedated and is not readily arousable, stop the PCA.As long as the patient has spontaneous respirations, instruct him or her to take deep breaths.Apply oxygen at 2 L via nasal cannula.Elevate the head of the bed 30 degrees, unless contraindicated, to facilitate respirations.Heavy sedation is not an expected outcome of PCA therapy.Evaluate for the presence of analgesic side effects.Maintain a slightly drowsy, easily aroused patient.

Question 13

The patient is in the hospital undergoing major abdominal surgery.When the patient returns from the recovery room, the nurse expects that he most likely will be receiving pain medication:

Accepted Answer

Research shows the epidural route to be most effective in managing postoperative pain from thoracic and abdominal surgeries.

Question 14

When assessing a local infusion pump site, the nurse notes that which of the following requires an intervention?

Accepted Answer

Assess the catheter connections; all should be firmly attached.If connections become detached, do not reattach because infection could occur.Notify the physician.The label on the device provides information regarding type of anesthetic, concentration, volume, flow rate, date and time prepared, and the name of the person who prepared it.The nurse should read this label.The dressing should be dry and intact.If not, stop the infusion and notify the physician.The catheter may not be placed properly.Assess for blood backing up in the tubing.If blood is present, stop the infusion and notify the physician.This indicates possible displacement of the catheter into a blood vessel.

Question 15

The patient is admitted with chronic pain.She states that nothing takes the pain away totally, but that "Dilaudid works best." The fact that the patient calls the medication by name should alert the nurse to:

Accepted Answer

It is important to assess the patient's acceptable level of comfort so that both you and the patient are striving for the same outcome.Some patients with prior pain conditions can alert the nurse to pain-relieving measures that were successful.Patients with chronic/persistent pain are often familiar with the names and actions of medications, including opioid medications.This should not cause you to view the patient negatively or with suspicion.Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new pain.Do not accept that "there is nothing that will help this patient's pain." Learn the institutional policy for how to proceed in this situation.

Question 16

The patient is admitted for chronic pain.He states that morphine sulfate (Morphine) has been used to relieve his pain, but recently he has been needing to use more of the medication to relieve pain.This patient's plan of care will have to incorporate interventions to deal with which of the following?

Accepted Answer

Drug tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time.Addiction is defined as a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors that influence its development and manifestations.It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.Pseudoaddiction is a term that describes patient behavior that may occur when pain is undertreated.Patients with unrelieved pain may focus on obtaining medications, may "clock watch," or otherwise may seem inappropriately "drug seeking." Even such behaviors as illicit drug use and deception can occur in the patient's efforts to obtain relief.Pseudoaddiction can be distinguished from true addiction in that behaviors resolve when pain is effectively treated.Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and/or administration of an antagonist.

Question 17

The patient is scheduled for surgery late in the afternoon.His postoperative orders include PCA therapy.Which of the following nursing interventions is appropriate to perform?

Accepted Answer

Instruct surgical patients preoperatively.Encourage the patient to push the button on the timing unit whenever he feels pain.Tell the patient not to delay if he is experiencing pain.Pain is easier to prevent than to treat.Inform the patient and family that the patient cannot overdose with PCA if only the patient pushes the button.The family should not push the button unless instructed to do so by the nurse.

Question 18

Before administering an epidural medication, the nurse aspirates and suspects that the catheter has migrated into the subarachnoid space when:

Accepted Answer

Aspiration of more than 1 mL of clear fluid or bloody return means that the catheter may have migrated into the subarachnoid space or into a vessel.Do not inject the drug.Notify the physician.Purulent drainage is a sign of infection, indicating that local inflammation and superficial skin infection at the insertion site have occurred.

Question 19

The patient is unable to rest even after pain medication has been administered.The nurse decides to give the patient a backrub.Which of the following strokes should the nurse use when finishing the backrub?

Accepted Answer

The nurse should end the backrub with long firm strokes down the back.This is the most soothing of massage movements.The backrub is not finished with light strokes while moving up the back in a circular motion.Kneading movements toward the sacrum are done before the backrub is ended with long firm strokes down the back.The nurse should begin a backrub by massaging in a circular motion upward from buttocks to shoulders.

Question 20

A nurse checks the continuous IV infusion for the intraspinal analgesia.The IV setup should be changed if:

Accepted Answer

Use tubing without Y-ports for continuous infusions.Use of tubing without Y-ports prevents accidental injection or infusion of another medication meant for vascular space into epidural space.Normal equipment used for intraspinal infusion includes an infusion pump and compatible tubing without Y-ports.Catheter and injection cap or infusion pump tubing should be securely taped and labeled.Closed, intact systems prevent entry of pathogens and disruption of the flow of medication.Medication should be prediluted, preservative-free opioid or local anesthetic as prescribed by the physician and prepared for use in an IV infusion pump (usually prepared by pharmacy).Preservatives may be toxic to nerve tissue.

Quiz 15: Pain Assessment and Basic Comfort Measures