1.After abdominal surgery a client reports pain. What action should the nurse take first?
A.Reposition the client.
B.Obtain the client’s vital signs.
C.Administer the prescribed analgesic.
D.Determine the characteristics of the pain.
2.A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is still experiencing pain. What should the nurse do first?
A.Monitor the client’s pain level for another hour.
B.Determine the integrity of the intravenous delivery system.
C.Reprogram the pump to deliver a bolus dose every 8 minutes.
D.Arrange for the client to be evaluated by the health care provider.
3.A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate?
A.Maintain the settings programmed by the health care provider.
B.Turn the machine on several times a day for ten to twenty minutes.
C.Adjust the dial on the unit until the client states the pain is relieved.
D.Apply the color-coded electrodes on the client where they are most comfortable.
4.A nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client?
5.Radium inserted in the vagina of a client is now being removed. What safety precaution should the nurse employ when assisting with the radium removal?
A.Clean the radium in ether or alcohol.
B.Wear foil-lined rubber gloves while handling the radium.
C.Ensure that long forceps are available for removing the radium.
D.Document how long the radium was in place and when it was removed.
The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery.
A, B, C,This should be done later; the first action is to determine the cause of the pain.
Client Need:Basic Care and Comfort;
Reference:Ch3,General Nursing Care of Clients in Pain
Initially,integrity of the intravenous system should be verified to ensure that the client is receiving medication.The intravenous tubing may be kinked or compressed,or the catheter may be dislodged.
A,Continued monitoring will result in the client experiencing unnecessary pain.
C,The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider’s prescription.
D,The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.
Client Need:Pharmacological and Parenteral Therapies;
Reference:Ch3,Related Pharmacology,Opioid Analgesics
The voltage or current is adjusted on the basis of the degree of pain relief experienced by the client.
A,This may provide too little or too much stimulation to achieve the desired response.
B,This is true of the pain suppressor transcutaneous electrical nerve stimulation (TENS) unit, not the conventional unit.
D,The electrodes should be applied either on the painful area or immediately below or above the area.
Client Need:Basic Care and Comfort;
Reference:Ch3,Nonpharmacologic Pain Management Strategies
Pain may indicate a toxic effect.
B, C,This is an expected side effect of internal radiotherapy.
D,This is associated with the need to maintain position, not with radium itself.
Client Need:Physiological Adaptation;
Radium must be handled with long forceps because distance helps limit exposure.
A,A nurse does not clean radium implants.
B,This does not provide adequate shielding from the gamma rays emitted by radium.
D,The amount and duration of exposure are important in assessing the effect on the client; however, this will not affect safety during removal.
Client Need:Safety and Infection Control;
Reference:Ch3, General Nursing Care of Clients with Neoplastic Disorders