Following surgery, a client refuses to ambulate as prescribed. what action should the nurse take?

The nurse is educating patients requiring surgery for various ailments on the perioperative experience. What education provided by the nurse is most appropriate?

Three phases of surgery and safety measures for each phase

The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical patients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the patients are having different surgeries. Intraoperative techniques, expected pain levels, and pain medication are specific to the patient and type of surgery. The risks and benefits of the surgical procedure should be discussed by the physician.

A patient has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?

“The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident.”

Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. The patient with unstable vital signs and a distended abdomen following a motor vehicle accident requires immediate attention. The patient with left sided abdominal pain may not need surgery. Epigastric pain with vomiting for 1 day is usually not an indication for emergent surgery. Lacerations to the face require sutures, not emergent surgery. A thyroidectomy to treat hyperthyroidism is a required surgery, not an emergent one.

An anxious preoperative surgical patient is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?

Imagery has proven effective for anxiety in surgical patients. Optimistic self-recitation is practiced when the patient is encouraged to recite optimistic thoughts such as, "I know all will go well." Distraction is employed when the patient is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.

A patient with fractured skull after falling from a ladder requires surgery. The nurse should anticipate transporting the patient to surgery during what time frame?

Emergent surgery occurs when the patient requires immediate attention. A fractured skull is an indication for emergent surgery. An urgent surgery occurs when the patient requires prompt attention, usually within 24–30 hours. Any surgery scheduled beyond 30 hours is classified as required or elective and a fractured skull does not meet the requirements for elective or required surgery.

A parent of a 16-year-old patient asks the nurse, “How could the surgeon operate without my consent?” What is the best response given by the nurse?

“Your child had life-threatening injuries that required immediate surgery.”

In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient's or parent’s informed consent. Informed consent must be obtained before any invasive procedure. A minor cannot consent for a surgical procedure. Two doctors’ opinions do not overrule the need to obtain informed consent.

The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery?

Vitamin K is important for normal blood clotting. Vitamin A and zinc deficiencies would affect the immune system, whereas a magnesium deficiency would delay wound healing.

A patient is scheduled for elective surgery. To prevent the complication of hypotension and cardiovascular collapse, the nurse should report the use of what medication?

Prednisone (Deltasone)

Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids can cause circulatory collapse and hypotension. Hydrochlorothiazide and erythromycin can cause respiratory complications. Warfarin will increase the risk of bleeding.

The nurse is educating a patient scheduled for elective surgery. The patient currently takes aspirin daily. What education should the nurse provide in regard to the medication?

Aspirin should be stopped at least 7 to 10 days before surgery. The other directions provided are incorrect.

A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all questions are answered fully for the patient.

The nurse is triaging the surgical patients. Which patient would the nurse document as urgent for surgical care?

An acute gallbladder infection is considered an urgent surgical procedure. Cosmetic surgery and cataract surgery are not considered urgent surgical procedures. Severe bleeding could be considered an emergent surgical procedure.

A patient continuously states, "I know all will go well." What cognitive coping strategy should the nurse document?

Optimistic self-recitation

When that patient verbalizes this statement, it is an optimistic response. Imagery occurs when the patient concentrates on a pleasant experience or restful scene. Distraction occurs when the patient thinks of an enjoyable story or recites a favorite poem or song. Music therapy would be an incorrect answer.

A patient asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate?

The major purpose of withholding food and fluid before surgery is to prevent aspiration, which can lead to respiratory complications. Preventing overhydration, decreasing urine output, and decreasing blood sugar levels are not major purposes of withholding food and fluid before surgery.

The nurse is educating a community group regarding types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?

An example of a curative surgical procedure is the excision of a tumor. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.

A patient is scheduled for an invasive procedure. What is the priority documentation needed regarding the procedure?

A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the patient’s signed consent form. A health history, medication reconciliation, and postoperative prescriptions are good items to have, but are not required documentation before performing an invasive procedure.

A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, “Why is everyone so concerned about how much I drink?” What is the best response by the nurse?

“It is important for us to know how much and how often you drink to help prevent surgical complications.”

Alcohol use and alcoholism can contribute to serious postoperative complications. If the medical and nursing staff is aware of the use or abuse, measures can be implemented proactively to prevent complications. Although alcohol may interfere with a medication’s effectiveness, it does not determine the amount of pain medications that are prescribed following surgery. Even though this is a required screening question and counselors can be made available for those who want help, those are not the best responses to answer the patient’s question.

An obese patient is scheduled for open abdominal surgery. What priority education should the nurse provide this patient?

the obese patient has an increased susceptibility to respiratory complications, and maintaining a patent airway would be the priority.

A patient is scheduled to have a cholecystectomy. Which of the nurse’s finding is least likely to contribute to surgical complications?

Osteoporosis is most likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system, increasing the chance for infections.

During the preoperative assessment, the patient states he is allergic to avocados, bananas, and hydrocodone (Vicodin). What is the priority action by the nurse?

Notify the surgical team to remove all latex-based items.

Allergies to avocados and bananas may indicate an allergy to latex. Although it is necessary to notify the dietary department and physician, it is not an immediate threat, as the patient is NPO (nothing by mouth) and pain medication will be ordered postoperatively. The nurse manager does not need to be notified of the patient’s allergies.

The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 taken orally, heart rate is 87, and blood pressure is 124/70. What is the nurse’s best action?

Notify the surgeon to possibly delay the surgery.

A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to care for the assessment findings but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour is not appropriate.

The nurse is completing a preoperative assessment. The nurse notices the patient is tearful and constantly wringing hands. The patient states, “I’m really nervous about this surgery. Do you think it will be ok?” What is the nurse’s best response?

Asking the patient about their concerns is an open-ended therapeutic technique. It allows the patient to guide the conversation and address their emotional state. Asking about family support is changing the subject and is nontherapeutic. Discussing the surgical team and the low death rate associated with a procedure is minimizing the patient’s feelings and is nontherapeutic.

What action by the nurse best encompasses the preoperative phase?

Educating the patients on signs and symptoms of infection

Educating the patient on prevention or recognition of complications begins in the preoperative phase. Applying SCD and frequent vital sign monitoring happens after the preoperative phase. Only electric clippers should be used to remove hair.

A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist with the prevention of respiratory complications. Pain medication should be taken regularly and not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some patients will find the exercises relaxing, most patients find it painful to complete the exercises.

A patient refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

Most facilities will allow a wedding band to remain on the patient during the surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the patient has already refused removal of the ring. The surgery should not be canceled and the ring should not be removed without permission.

The nurse has administered the preanesthetic medication. What action should the nurse take next?

Place the patient on bed rest with the side rails up.

The preanesthetic medication can make the patient lightheaded and dizzy. Safety is a priority. The consent form should be signed before the patient is medicated. Consents signed after the patient is medicated are not legal. Reviewing the home medications and educating the patient should take place before the patient is medicated.

A nurse assesses a postoperative patient to have the protrusion of abdominal organs through the surgical incision. Which term, documented by the nurse, best describes the assessment findings?

Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

Postoperative day 2, a patient requires wound care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline dressing and covered with a dry dressing. The edges of a second-intention healing wound are not approximated. The wound may be cleaned using sterile saline but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed impairing healing.

When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation via the O2 saturation monitor, although the patient's breathing appears normal what action should the nurse take first?

Assess the patient's heart rhythm and nail beds.

A patient may demonstrate low oxygenation readings due to wearing certain colors of nail polish or irregular heart rate such as atrial fibrillation. These items should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.

A recently extubated postoperative patient starts to gag and make vomiting sounds. What action should the nurse do first?

The nurse should turn the patient on her side to avoid aspiration. The nurse may need to obtain suction equipment, provide an emesis basin, or administer and antiemetic but the first priority is protecting the patient’s airway by preventing aspiration.

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the patient to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring the vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

Which actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient?

The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The patient may be given low-dose heparin for prophylaxis treatment but not a high-dose heparin. The nurse should instruct the patient not to prop a pillow under the knees because the patient can constrict the blood vessels.

A patient has undergone hernia repair surgery without complications. In the immediate postoperative period, which of the following actions by the nurse is most appropriate?

The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Obtaining an arterial blood gas every 5 minutes is painful to the patient unless a special device is inserted to obtain arterial blood samples. Without complications, this is not indicated for the patient. Urinary output is monitored frequently but usually measured hourly. While it may be necessary to assess pupillary response during the immediate postoperative phase, it does not need to be done every 5 minutes.

The nurse is caring for a postoperative patient with an indwelling urinary catheter. The hourly urinary output at 9 am is 80 mL. The nurse assesses the hourly urinary output at 10 am at 20 mL. What is the highest priority action by the nurse?

Notify the physician.

If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/h are reported. Any urinary output less than 30 mL/h should be reported to the physician immediately. The urinary output will be reassessed at 11 am but waiting to notify the physician could cause harm to the patient. The findings should be documented but this is not the highest priority. A urinary catheter may need to be irrigated but a postoperative patient with a low urinary output is demonstrating a complication that needs to be reported immediately.

A patient is postoperative day 3 for surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

The patient has an increased risk for infection related to the surgical wound classification of dirty. Assessing the WBC count, temperature, and wound appearance will allow the nurse to intervene at the earliest sign of infection. The patient will have special nutritional needs for wound healing and need education on safe transfer procedures but the need to monitor for infection is a higher priority. The patient should receive pain medication as soon as possible after asking but the latest literature suggest that pain medication should be given on a schedule versus “as needed.”

Which of the following should be incorporated into the patient teaching plan to prevent deep vein thrombosis?

The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible patients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation.

A postoperative patient, with an open abdominal wound is currently taking corticosteroids. The physician orders a wound culture of the abdominal wound even though there are no signs and symptoms of infection. What action by the nurse is appropriate?

Obtain the wound culture specimen.

Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the patient is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the patient will possibly develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.

A patient with an abdominal surgical wound sneezes and states, “Something doesn’t feel right with my wound.” The nurse asses the upper half of the surgical wounds edges are no longer approximated and the lower half remains well approximated. What documentation by the nurse is most appropriate?

Following a sneeze, the wound dehisced.

Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules Hemorrhage is excessive bleeding.

What is the highest priority nursing intervention for a patient in the immediate postoperative phase?

Maintaining a patent airway.
The highest priority intervention is maintaining a patent airway. Without a patent airway, the other interventions of monitoring vital signs and urinary output, along with assessing for hemorrhage, become secondary to the possibility of a lack of oxygen.

A PACU nurse receives a postoperative patient who received general anesthesia with a hard plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and an oxygen saturation of 98%. The patient is minimally responsive to painful stimuli. What action by the nurse is most appropriate?

Continue with frequent patient assessments.

An immediate postoperative patient may be transferred to the PACU with a hard plastic oral airway. The airway should not be removed until the patient is showing signs of gagging or choking. The neurological status is appropriate for a patient that received general anesthesia. There is no information provided that requires the patient to have vitals taken more frequently than the standard 15 minutes. The nurse should continue with frequent patient assessments.

The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97.2°F oral, blood pressure 84/50. What should the nurse do first?

Assess for bleeding.

The patient is tachycardic with a low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the patient, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed.

A postanesthesia care unit (PACU) nurse is caring for a patient with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate?

a) Maintain a patent airway.

c) Frequently monitor neurological status.

d) Apply oxygen per orders.

f) Administer blood products per orders.

The patient is demonstrating signs and symptoms of shock. The patient in shock may lose the ability to protect his or her airway. Frequently neurological assessment can provide information related to decrease oxygen to the brain. Administering the blood products may reverse the signs and symptoms of shock. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen. The head of the bed should not be elevated. The patient should be lying flat or in the Trendelenburg position. Applying a warming blanket when the patient is not hypothermic may cause vasodilation, which could further decrease blood pressure and perfusion to vital organs.

A patient is postoperative hour 8 following an appendectomy and is anxious stating, “Something is not right. My pain is worse than ever and my stomach is swollen.” Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate?

The physician should be notified of the findings. The patient may be hemorrhaging internally and may need to return to surgery. The patient may be in need of pain medication but morphine will lower the blood pressure further and may cause further complications. Ambulating the patient increases the risk of injury because the patient may experience orthostatic hypotension. What the patient is experiencing is not the normal progression following abdominal surgery.

The nurse has medicated a postoperative patient for complaints of nausea. Which medication would the nurse document as having been given?

Odansetron (Zofran) is an antiemetic and one of the most commonly prescribed medications for nausea and vomiting. Warfarin (Coumadin) is an anticoagulant. Prednisone (Deltasone) is a corticosteroid. Propofol (Diprivan) is an anesthetic agent.

A 76-year-old patient had surgery for an abdominal hernia. The PACU nurse assesses that the patient is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate?

a) Assess for hypoxia.

b) Assess for urine output.

e) Reorient the patient.

f) Administer opioid pain medication per orders.

The nurse should provide reassurance and reorient the patient as needed. Hypoxia and urinary retention may cause acute confusion in the older adult postoperative patient, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; consultation with the physician about the type and dosage of the pain medication should occur. Ambulating the patient may be a safety issue, especially if the patient is bleeding or hypoxic. Applying wrist restraints should only be used as a last resort.

A postanesthesia care unit (PACU) nurse is preparing to discharge a patient home following ankle surgery. The patient keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate?

Review the instructions with the patient and accompanying adult.

The effects of the anesthesia may impair the memory or concentration of the patient. It is important that the discharge instructions are covered with the patient and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instruction until the patient restates them does not ensure that the patient will remember them because of how anesthesia can impair the memory. Asking if the patient understands the instructions only elicits an yes or no answer but does not give insight on if the patient comprehending the instructions.

A postoperative patient is being discharged home following minor surgery. The PACU nurse is reviewing discharge instructions with the patient and his or her spouse. What action by the nurse is appropriate?

a) Discuss wound care.

c) Have the spouse review when to notify the physician.

d) Provide information on health promotion topics.

e) Educate on activity limitations.

The nurse should provide education on activity limitations, wound care, and review complications that require notification to the physician. The nurse should also provide information regarding health promotion topics, such as, weight management and smoking cessation. The patient should not make any major decisions or sign any legal forms due to the effects of anesthesia.

A patient is postoperative day 1 from abdominal surgery. The patient is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

The patient’s 24 hour intake is 1,800 mL (75x24). The patient’s 24 hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Since the output is significantly higher than the intake the patient is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician’s order. The findings should be documented and reassessed but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

The nurse is attempting to ambulate a patient who underwent shoulder surgery earlier in the day. The patient is refusing to ambulate. What action by the nurse is most appropriate?

Reinforce the importance of early mobility in preventing complications.

The patient may be refusing to ambulate because of fear or pain. Educating on the importance of mobility in preventing complications may encourage the patient to ambulate. The nurse should try all reasonable measures (pain control, education) before documenting the patient’s refusal to ambulate. If the patient is already refusing to ambulate delegating the task to the unlicensed assistive personnel is not an appropriate action. The patient should not be forcefully removed from the bed.

A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection."

A wound drain assists in preventing infection by removing the medium in which bacteria would grow. The purpose of the wound drain is not to remove necrotic tissue or to decrease the number of dressing changes. Stating that most surgeons use wound drains does not answer the patient‘s question appropriately.

A postoperative patient begins coughing forcefully when eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?

Placing the patient in low Fowler’s position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first and foremost the nurse should minimize further protrusion of the intestines.

When a person who has been taking opioids becomes less sensitive to the drug’s analgesic properties, that person is said to have developed which of the following?

Tolerance is characterized by the need for increasing dose requirements to maintain the same level of pain relief. Addiction refers to a behavioral pattern of substance use characterized by a compulsion to take the drug primarily to experience its psychic effects. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Balanced analgesia occurs when the patient is using more than one form of analgesia concurrently to obtain more pain relief with fewer side effects.

Prostaglandins are chemical substances with which of the following properties?

Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

Which of the following is a true statement regarding placebos?

A placebo should never be used to test the person's truthfulness about pain.

Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. The American Society for Pain Management Nurses contends that placebos should not be used to assess or manage pain in any patient, regardless of age or diagnosis. Reduction in pain as a response to placebo should never be interpreted as an indication that the person’s pain is not real.

The nurse understands that which of the following is true about tolerance and addiction?

Although patients may need increasing levels of opioids, they are not addicted.

Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare, and should never be the primary concern for a patient in pain.

The preferred route of administration of medication in the most acute care situations is through which of the following routes?

IV is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. Subcutaneous administration results in slow absorption of medication. Intramuscular administration of medication is absorbed more slowly than IV-administered medication.

The nurse needs to carefully monitor a patient with traumatic injuries. Which of the following actions by the nurse demonstrates understanding of the most essential component of the patient’s pain assessment?

The nurse administers pain medication based on the patient’s reported pain level.

Patients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated BP or heart rate does not mean the absence of pain. The ability of an individual to give a report, in the case of pain—especially its intensity—is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the patient. Pain medication should not routinely be administered to a patient on admission to the unit.

About which of the following issues should the nurse inform patients who use pain medications on a regular basis?

Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician.

Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. OCT analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

Which of the following nursing interventions should a nurse perform when caring for a patient who is prescribed opiate therapy for pain?

The nurse should not administer the prescribed opiate therapy if respirations are less than 12 per minute. The nurse should instruct a patient who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose level when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which of the following actions illustrates the nociception process of pain transmission?

A child quickly removing a hand when touching a hot object

Transduction, the first process involved in nociception, refers to the processes by which noxious stimuli, such as a surgical incision, release of a number of excitatory compounds which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual mechanism analgesic agent, such as tramadol (Ultram), involves many different neurochemicals as in the process of modulation.

When taking a patient history, the nurse notes that the patient has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the patient is experiencing which of the following types of pain after an amputation?

Chronic pain persists over a course of time, in this case several years. Acute pain has a relatively short duration. Breakthrough pain is acute exacerbations of pain periodically experienced by patients with a normally controlled pain management regimen. Patients who have a history of amputation commonly report phantom pain in the amputated extremity.

Which of the following, approved by the United States Food and Drug Administration, is the only use for lidocaine 5% patch (Lidoderm)?

Postherpetic neuralgia

A lidocaine 5% (Lidoderm) patch has been shown to be effective in postherpetic neuralgia. Lidoderm has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

A patient is being treated in a substance abuse unit of a local hospital. The nurse understands that when a patient has compulsive behavior to use a drug for its psychic effect, the patient needs to be monitored for which of the following?

Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a person who has been taking opioids becomes less sensitive to their analgesic properties.

Which of the following route of medication administration should the nurse consider first in an NPO (nothing by mouth) postoperative patient following IV removal?

The rectal route of analgesic administration is an alternative route when oral or IV analgesic agents are not an option. The rectum allows passive diffusion of medications and absorption into the systemic circulation. Topical agents produce effects in the tissues immediately under the site of application. Intrathecal catheters for acute pain management are used most often for providing anesthesia or a single bolus dose of an analgesic agent. The subcutaneous route of administration is not recommended in this situation.

When administering a fentanyl patch, the last dose of sustained-release morphine should be administered at what point?

At the same time the first patch is applied

The skin must be clean and dry prior to patch application; no shower is required. Respiratory assessment must be conducted prior to applying the fentanyl patch. Because it takes 12 to 24 hours for the fentanyl levels to increase gradually from the first patch, the last dose of sustained-release morphine should be administered at the same time the first patch is applied. The other time frames are incorrect.

A patient has been prescribed a Fentanyl patch for pain control. The nurse understands that this patch should be replaced how often?

Fentanyl patches should be replaced every 72 hours.

A high school football player hurts his foot while playing a game. He complains of intense pain with muscle spasms and swelling of the toe. Which of the following pain assessment tools will the nurse most likely use to assess the patient’s pain level?

The numeric rating scale (NRS) is most appropriate for this patient. The VDS requires the patient to use words or phrases; in this situation, intense pain may affect the patient’s ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice.

A 75-year-old patient had surgery for her hip fracture yesterday. She is under stress due to the pain, the medications, sleep deprivation, and hospital surroundings. Which of the following nursing interventions to treat the patient’s pain when ordered by the doctor should the nurse question?

NSAIDs, such as Advil, increase the risk of GI toxicity in individuals older than 60 years and should be assessed further prior to administration. There are many risk factors for opioid-induced respiratory depression in individuals older than 65 years; a thorough respiratory assessment is indicated. Acetaminophen should be used for mild pain. Nonpharmacologic methods of pain management, such as TENS, are acceptable in this situation. Society has proposed that opioids are a safer choice than NSAIDs in many older adults because of the increased risk for NSAID-induced GI adverse effects in that population.

What pain assessment scale would be best to use with a 5-year-old child?

The FACES scale was developed for use in children. It consists of six pictures depicting faces ranging from content to distressed. The child points to the face that best shows how much he or she hurts. The FACES scale may also be useful for adults who have difficulty with numerical or visual analog scales. Specific pain assessment scales have been tested for use in many patient populations from neonates to patients who have dementia. The Visual Analog Scale and Numerical Pain Scale are not the best choices for a 5-year-old because they depend on the patient being able to read and use numbers.

A home health nurse is visiting a patient who has been taking the same dose of hydrocodone/acetaminophen (Lortab) for 2 months. To monitor for the presence of expected side effects of this medication, what should the nurse include in the assessment of the patient?

Ask about the patient's bowel pattern.

Opioids can result in delayed gastric emptying, slowed bowel motility, and decreased peristalsis, all of which result in slow-moving, hard stool that is difficult to pass. Constipation is a very common side effect of narcotics that continues to be a problem, even with chronic administration. Although respiratory depression, decreased level of consciousness, and hypotension are common side effects of acute use of narcotics, these effects are not expected to occur with chronic usage at the same dose.

The advance practice nurse is treating a patient experiencing a neuropathic pain syndrome. Which of the following statements when made by the patient demonstrates an understanding of concepts related to neuropathic pain?

“My phantom limb pain serves no purpose, and I may need to take antidepressants to help.”

Neuropathic pain is chronic and not treated with COX-2 analgesics. Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the TCAs despiramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for neuropathic pain treatment.

The advance nurse practitioner treating a patient diagnosed with neuropathic pain decides to start adjuvant analgesic agent therapy. Which of the following medications is appropriate for the nurse practitioner to prescribe?

The anticonvulsants gabapentin (Neurontin) is a first-line analgesic agent for neuropathic pain. Tramadol (Ultracet) is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine (Ketalar) is used as a third-line analgesic agent for refractory acute pain. Hydromorphone (Dilaudid) is a first-line opioid not used as an analgesic agent for neuropathic pain.

Which of the following actions when performed by the nurse indicates understanding of one basic principle of providing effective pain management?

Awakening postoperative patients with moderate-to-severe pain to take pain medication is especially important during the first 24 to 48 hours after surgery to keep pain under control. The PCA is an interactive method of pain management that allows patients to treat their pain by self-administering doses of analgesic agents and should not be used by the nurse.

Which of the following statements when made by a cancer patient with moderate-to-severe pain prescribed oxymorphone (Opana IR) indicates further instruction is required?

“I will take this medication with breakfast for the best results.”

Oxymorphone (Opana IR) must be taken on an empty stomach (1 hour before or 2 hours after a meal). Co-ingestion of alcohol can increase the serum concentration of the drug. Oxymorphone has been available for many years in parenteral formulation and more recently in short-acting (Opana IR) and modified-release (Opana ER) oral tablets.

For which of the following reasons are nonpharmacologic pain management techniques employed?

b) They allow patients to match the technique to their own individual and cultural preferences.

c) They help decrease the sensation of pain.

e) They help decrease the distress the patient experiences from pain.

Nonpharmacologic pain management techniques are usually used in conjunction with medications and help to decrease the sensation of pain and the distress the patient experiences from pain. Nonpharmacologic methods are used to complement, not replace, pharmacologic methods. Many patients find that the use of nonpharmacologic methods helps them cope better with their pain and feel greater control over the pain. Nonpharmacologic methods do not have any relationship to a patient’s risk of becoming addicted to pain medications. A variety of techniques allows them to match the technique to their own individual and cultural preferences.

The nurse understands the definition of pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Which of the following comments when made by the patient confirms patient understanding of the fundamental concepts of pain?

a) “I am tired of living with this nagging pain; I’m not sure how much longer I can go on.”

c) “I would love to go to church, but my back pain is too uncomfortable to make it through the service.”

e) “I used to walk every day for exercise; pain in my knee made me stop walking.”

A fundamental concept of pain is that pain is a complex phenomenon that can affect a person’s psychosocial, emotional, and physical functioning. Helplessness is an emotional response to pain. Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. Inability to perform normal exercise because of pain is a physical restriction related to pain. Pain is highly personal and subjective. The patient’s report is the most reliable indicator of pain. The patient works with the nurse and doctor to establish a pain management regimen.

Painless chancre lesions are associated with which systemic disease?

Syphilis is manifested by a painless chancre lesion. Psoriasis is exhibited by plaques with scales. Kaposi's sarcomas are cutaneous lesions blue-red or dark brown in color. Urticaria is wheals or hives due to infection or allergic reactions.

Which of the following is the usual incubation period (infection to first symptom) for AIDS?

AIDS is transmitted through sexual, percutaneous, or perinatal contact. The median incubation period for AIDS infection is 10 years.

The nurse is educating a group of people on hepatitis B. One participant asks what is the usual incubation period for hepatitis B. Which of the following responses by the nurse is appropriate?

Hepatitis B is responsible for more than 200 deaths of health care workers annually. The incubation period for hepatitis B is 45 to 160 days. The incubation periods for hepatitis D, E, and G are unclear.

Which of the following terms refers to a state of microorganisms being present within a host without causing host interference or interaction?

Colonization

Understanding the principle of colonization facilitates interpretation of microbiologic reports. A susceptible host is a host that does not possess immunity to a particular pathogen. An immune host is a host that is not susceptible to a particular pathogen. Infection refers to host interaction with an organism.

The parent of a child diagnosed with chickenpox asks when the child can go to play group again. What is the best response by the nurse?

When the lesions have crusted, the patient is no longer contagious to others. The child remains contagious when the rash is present, and if the fever occurs as the rash is progressing. The child is still contagious when the rash is changing into vesicles and pustules.

The nurse is teaching about West Nile virus. Which statement by the nurse is accurate?

“There is no treatment for West Nile virus infection.”

Patients with West Nile virus are supported by fluid replacement, airway management, and standard nursing care while the patient has meningitis symptoms. The incubation period (from mosquito bite until onset of symptoms) is between 5 and 15 days. Most human infections are asymptomatic. When symptoms are present, headache and fever are most frequently reported. Less than 1% of those infected develop more severe illness, including meningitis. Birds are the natural reservoir for the virus. Mosquitoes become infected when feeding on birds and can transmit the virus to animals and humans.

Which statement reflects what is known about the Ebola and Marburg viruses?

The diagnosis should be considered in a patient who has a febrile, hemorrhagic illness after traveling to Asia or Africa, or who has handled animals or animal carcasses from those parts of the world. Antibiotic therapy, such as penicillin, would not be effective for the treatment of viruses. Treatment must be largely supportive maintenance of the circulatory and respiratory systems. The infected patient likely would need ventilator and dialysis support through the acute phases of illness. The viruses are usually spread by exposure to blood or other body fluid, insect bite, and mucous membrane exposure. Symptoms include fever, rash, and encephalitis which progress rapidly to profound hemorrhage, organ destruction, and shock.

Which intervention should a nurse perform after administering an injection of penicillin to a patient with an infection?

After administering injections of penicillin, the nurse should make the patient wait at least 30 minutes before allowing him or her to leave the health care facility. This is because reactions are frequent and can be severe enough to be fatal. The muscle in which the injection is given does not need to be massaged. There is no indication for the patient to deep breathe or to lie flat for 6 hours following the injection.

The nurse is required to manage and minimize sepsis in a patient with severe infection. Which of the following would be an appropriate nursing intervention?

When caring for a patient susceptible to developing sepsis, the nurse should monitor vital signs every 4 hours or as ordered medically, because changes may be the earliest indication of sepsis. The nurse should also encourage fluid and food intake in the patient, as sufficient intake helps restore biologic defense mechanisms. The patient may be weak and, therefore, need not be encouraged to perform mild activity.

Which of the following terms describes the time interval after primary infection when a microorganism lives within the host without producing clinical evidence?

Latency is the time interval after primary infection when a microorganism lives within the host without producing clinical evidence. Virulence is the degree of pathogenicity of an organism. The incubation period is the time between contact and onset of signs and symptoms. Susceptibility is not possessing immunity to a particular pathogen.

What is the mode of transmission for tetanus?

The mode of transmission for tetanus is a puncture wound. Saliva is the mode of transmission for roseola infantum. Droplet inhalation is the mode for mycoplasmal pneumonia. A bite from an infected tick is the mode of transmission for the West Nile virus.

The nurse is completing the admission assessment on a patient with renal failure. The patient states, “I was diagnosed with impetigo yesterday.”

Impetigo is a bacterial infection transmitted via contact. Therefore, the nurse should initiate contact isolation protocol. The patient would not be taking an antiviral medication for impetigo, would not need a negative pressure room, and would not wear a mask when outside the room.

When a hospitalized patient is in contact precautions, which of the following responses is necessary?

When possible, the patient requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed, doors do not need to be closed, and a room with negative air pressure is not required.

The nurse is caring for a patient diagnose with severe acute respiratory syndrome (SARS). A family member asks what causes SARS.

SARS is caused by the coronavirus.

Which of the following can be used for rehydration therapy for diarrheal disorders?

Oral Rehydration Solution

ORS may be used for rehydration therapy for diarrheal disorders. Foods that are high in simple sugars, such as undiluted apple juice or gelatin, should be avoided. Sports drinks do not replace fluid losses correctly and should not be used.

Which organism is responsible for impetigo?

Staphylococcus aureus is the responsible organisms for impetigo. Histoplasma capsulatum is responsible for histoplasmosis. Bacillus anthracis is responsible for anthrax. Clostridium difficile is responsible for some diarrheal diseases.

The nurse is observing a nursing assistant leave the room of patient diagnosed with Clostridium difficile (C. difficile) without washing hands. Which of the following is the highest priority action the nurse should follow?

Have the nursing assistant wash hands with soap and water.

Although all actions listed are appropriate, the priority nursing action is to ensure that nursing assistants wash their hands with soap and water. Allowing nursing assistants to continue with their job without washing their hands will lead to the nursing assistant infecting other patients with whom they come in contact. The potential for health care–associated acquisition is increased because the spore is relatively resistant to disinfectants and can be spread on the hands of health care providers.

The nurse observes a physician leave the room of a patient in isolation for Clostridium difficile (C. difficile). The physician uses the alcohol-based hand sanitizer hanging on the wall to wash her hands and leaves the door open. Which of the following actions should the nurse take?

C. difficile is resistant to alcohol-based and other hand sanitizers; therefore physicians should be instructed to wash their hands with soap and water. The nurse could report the observation to the infection control department, but that does not address the immediate concern of the physician contaminating other patients. There is no need for the room door to be closed. The nurse must take action to ensure the safety of other patients.

A patient is placed in isolation for suspected tuberculosis. Which of the following actions should the nurse take when entering the patient’s room?

Tuberculosis is acquired via airborne transmission. With airborne precautions, the room door must remain shut to ensure the effectiveness of the negative pressure room. All personnel entering the room should wear an N-95 respirator or similarly approved respirator. A simple face mask with an eye shield is not an effective barrier to stop transmission. There is no need to minimize verbal interactions with a patient with tuberculosis.

A patient diagnosed with influenza is admitted to the hospital. Which of the following transmission-based precautions should the nurse initiate?

Influenza is transmitted via droplets; therefore, the nurse should initiate droplet precautions. Tuberculosis and varicella would qualify for airborne precautions. Contact precautions are used for organisms that are transmitted by skin-to-skin contact. Neutropenic (or reverse) precautions are used for immunosuppressed patients.

A 36-year-old patient is in the clinic for an annual physical. The patient asks the nurse “should I get a flu shot.” Which of the following is the best response by the nurse?

The influenza vaccine is recommended for all people over 6 months of age. The patient is in the recommended age range. Ascertaining if the patient has any chronic illnesses is important, but it does not change the recommendation by the Centers for Disease Control and Prevention. There is no recommendation that the immunization be given only if the patient works around children or the elderly.

The nurse is scheduled to administer tetanus, diphtheria, and pertussis (Tdap) vaccine to a patient at the clinic. The patient states, “I had a reaction the last time I got an immunization.” What action should the nurse take first?

The nurse should withhold the immunization until a further investigation of the type of reaction and immunization received is completed. Patients who have had serious reactions or encephalopathy after receiving the pertussis vaccine should not receive the vaccine again. The patient may suffer a severe reaction if the Tdap is administered without investigation. Documentation of the reaction cannot happen until the nurse receives further information.

The nurse is instructing the family on home care of a patient with shingles. The family member asks if their teenage children should stay in a different room. What is the best response by the nurse?

To answer the question correctly, the nurse needs to know if the children had chickenpox or the varicella vaccine. If the children had the vaccine or the disease, then they are considered immune and no precautions are needed. If the children have not been vaccinated for chickenpox nor had the disease, it would be best to maintain distance. Shingles is contagious. Even though the patient may be in pain, this should not guide the nurse’s response.

A patient in the clinic is diagnosed with diarrhea caused by Campylobacter. Which of the following instructions should the nurse provide to prevent further episodes?

Campylobacter infection is caused by the consumption of undercooked or raw meat. Proper storage and cooking of meat will prevent further episodes of Campylobacter. The patient should also be told to prepare meat separately from other foods, including the use of utensils. Giardia lamblia diarrhea is caused by drinking contaminated water. Shigella infection is transmitted via the fecal–oral route, so hand washing after going to the bathroom would help prevent the illness. Salmonella infections are usually caused by consuming raw eggs; it also can be transmitted via produce.

A patient complains of nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes to be pale and dry. The patient has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which of the following is the priority nursing intervention?

The patient is demonstrating hemodynamic instability that could lead to shock, therefore IV rehydration therapy is indicated for this patient. Once the patient becomes hemodynamically stable, then oral rehydration therapy may begin. Although it is appropriate for the nurse to take vital signs frequently, the patient needs fluid replacement and that need should be addressed first. Stool specimens can be obtain once the patient is hemodynamically stable.