7/17/2019 Pain Assessment

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1. A patient receiving pain medication via a patient-controlled analgesia (PCA) pumps statesthat his pain is getting worse. What actions by the nurse are most appropriate?

A. Review the number o times the patient pushed the PCA button as well as how many

doses were delivered

B. !otiy the physician o the patient"s current status ater chec#ing the intravenous site

C. Raise the patient"s head slightly ater repositioning in an attempt to ma#e the patient

more comortable

D. $ind out the patient"s pain level ollowed by administration o a dose o antian%iety

medication

&his evaluation assists in determining the eectiveness o the PCA dose and the re'uency in

relieving pain. &he ne%t thing to be assessed would be the status o the patient"s intravenous line

and the PCA pump. Page

Points Earned: *+,

Correct Answer: A

Your Response:

2. A patient rom a nursing home with bilateral paralysis rom a stro#e and a clotting disorder

has a PCA pump ordered ater surgery. What intervention should be ta#en by the nurse to

best meet this patient"s needs?

A. how the patient how to push the button on the PCA machine

B. Contact the physician regarding using a continuous dose o pain medication

C. As# the patient i there is someone who can stay at the hospital while PCA is being used

D. $ind out rom the physician i pain medication can be given intramuscularly on a PR!

basis&he patient is unable to manipulate the PCA button because o the prior stro#e. ecause thepatient has a clotting disorder/ the patient is not a good candidate or intramuscular in0ections.

&he best approach would be most li#ely be a continuous inusion/ but at a low dose. Page 1

Points Earned: *+,

Correct Answer:

Your Response:

. A patient is to have a bolus o pain medication administered through an epidural catheter. An

intervention is indicated i which action by the nurse is observed?

A. Preservative-ree medication is drawn up

B. Alcohol is used to prep the in0ection port

C. &he in0ection port is cleaned with povidone-iodine

D. &he patient"s sedation level is monitored ater the medication is given

Alcohol causes pain and is to%ic to neural tissue. All o the other options are correct. Page 2

Points Earned: *+,

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!. 3uring assessment o a patient with an epidural catheter/ the nurse sees blood on the

7/17/2019 Pain Assessment

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epidural dressing. What action is most important or the nurse to ta#e initially?

A. Assess the patient"s vital signs and o%ygen saturation

B. top the inusion o the epidural pain medication

C. As# the patient how she is eeling in general

D. Perorm a complete head-to-toe assessment

lood seen on the dressing indicates that the catheter has probably punctured a blood vessel.

&he inusion needs to be stopped and the physician notiied. Page 2*

Points Earned: *+,

Correct Answer:

Your Response:

5. A patient has a local analgesia inusion pump with the catheter in the shoulder where the

surgery was perormed. ince the catheter will be removed by a amily member/ the patient

and amily teaching needs to include which statement by the nurse?

A. 45nce the catheter is removed/ put a and-Aid over the opening.4

B. 46 you meet resistance while removing the catheter/ stop and cover the site.4

C. 4As# the patient what his pain level is beore you remove the catheter.4

D. 4Wash your hands irst/ then remove the dressing/ then the catheter.4

&he catheter is either twisted or in an unusual position in the shoulder and should be let or the

physician to remove. &he catheter needs to be removed when the pump inishes delivering themedication regardless o the patient"s pain level. &he patient has oral pain medication along with

the pump. 5ption 1 did not include the use o gloves which is necessary. Page 27

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