Question 1

A client has a PCA pump and the nurse determines the client's Pasero score is 4. What action by the nurse is most appropriate?

Accepted Answer

A)  Document the score in the medical record. 
B)  Turn the PCA pump off immediately. 
C)  Reassess the client's pain with a pain scale. 
D)  Notify the provider and ask for naloxone. 
A)  Document the score in the medical record. 
B)  Turn the PCA pump off immediately. 
C)  Reassess the client's pain with a pain scale. 
D)  Notify the provider and ask for naloxone.

Question 2

The nurse has prepared a PCA pump for a client. The nurse has educated the client, completed the independent safety checks, and has ensured the medication cassette is loaded properly. What action does the nurse take next?

Accepted Answer

A)  Turn the pump on at the basal rate. 
B)  Have a second nurse verify the safety checks. 
C)  Have the client demonstrate PCA use. 
D)  Document the procedure in the record. 
A)  Turn the pump on at the basal rate. 
B)  Have a second nurse verify the safety checks. 
C)  Have the client demonstrate PCA use. 
D)  Document the procedure in the record.

Question 3

A client is in the Emergency Department reporting severe pressure in the chest. When the nurse asks the client to rate the pain on a scale, the client states "I don't have pain." What is the best action for the nurse to take?

Accepted Answer

A)  Use an observational tool instead. 
B)  Use the word "pressure" in the assessment. 
C)  Tell staff you aren't sure there really is pain. 
D)  Withhold medication until pain is quantified. 
A)  Use an observational tool instead. 
B)  Use the word "pressure" in the assessment. 
C)  Tell staff you aren't sure there really is pain. 
D)  Withhold medication until pain is quantified.

Question 4

For safety, which of the following actions are priorities when caring for clients on epidural pain control? (Select all that apply.)

Accepted Answer

A)  Ensure naloxone and oxygen are available at the bedside. 
B)  Cover any injection ports on the tubing with tape. 
C)  Clearly label tubing close to the entry site and pump. 
D)  Infuse only solutions with active preservatives. 
E)  Cover the insertion site with several gauze dressings.
F) Tape the tubing securely to the client without tension. 
A)  Ensure naloxone and oxygen are available at the bedside. 
B)  Cover any injection ports on the tubing with tape. 
C)  Clearly label tubing close to the entry site and pump. 
D)  Infuse only solutions with active preservatives. 
E)  Cover the insertion site with several gauze dressings.
F) Tape the tubing securely to the client without tension.

Question 5

A known drug-abusing client had a knee replacement. One month later the client is admitted for severe pain in that knee. The nursing staff is slow to provide pain medications because the client is "obviously addicted and just wants more medication." What action by the nurse manager is most appropriate?

Accepted Answer

A)  Remind the staff that there are standards related to pain control. 
B)  Conduct a "lunch-n-learn" on chemical dependency. 
C)  Ask the nursing staff to evaluate their beliefs about pain. 
D)  Inform the staff that even people with addictions can have pain. 
A)  Remind the staff that there are standards related to pain control. 
B)  Conduct a "lunch-n-learn" on chemical dependency. 
C)  Ask the nursing staff to evaluate their beliefs about pain. 
D)  Inform the staff that even people with addictions can have pain.

A client has a PCA pump and the nurse determines the client's Pasero score is 4. What action by the nurse is most appropriate?

The nurse has prepared a PCA pump for a client. The nurse has educated the client, completed the independent safety checks, and has ensured the medication cassette is loaded properly. What action does the nurse take next?

A client is in the Emergency Department reporting severe pressure in the chest. When the nurse asks the client to rate the pain on a scale, the client states "I don't have pain." What is the best action for the nurse to take?

For safety, which of the following actions are priorities when caring for clients on epidural pain control? (Select all that apply.)

Foundations of Safe Client Care

Personal Care and Hygiene

Vital Signs and Vital Measurements

Performing an Assessment

Nutrition and Gastrointestinal Tube Therapy

Supporting Mobility and Immobilization

End-Of-Life Care

Airway and Breathing

Sterile Technique

Medication Administration

Venous Access

Central Venous Access

Bowel Management

Urinary Elimination

Wound Care

Perioperative Care

Advanced Respiratory Management

Advanced Cardiovascular Care

Advanced Neurologic Care

Filters

Exam 7: Comfort Care

A client has a PCA pump and the nurse determines the client's Pasero score is 4. What action by the nurse is most appropriate?

The nurse has prepared a PCA pump for a client. The nurse has educated the client, completed the independent safety checks, and has ensured the medication cassette is loaded properly. What action does the nurse take next?

A client is in the Emergency Department reporting severe pressure in the chest. When the nurse asks the client to rate the pain on a scale, the client states "I don't have pain." What is the best action for the nurse to take?

For safety, which of the following actions are priorities when caring for clients on epidural pain control? (Select all that apply.)

Foundations of Safe Client Care

Personal Care and Hygiene

Vital Signs and Vital Measurements

Performing an Assessment

Nutrition and Gastrointestinal Tube Therapy

Supporting Mobility and Immobilization

End-Of-Life Care

Airway and Breathing

Sterile Technique

Medication Administration

Venous Access

Central Venous Access

Bowel Management

Urinary Elimination

Wound Care

Perioperative Care

Advanced Respiratory Management

Advanced Cardiovascular Care

Advanced Neurologic Care

Filters