Skills In Clinical Nursing  8th Edition by Audrey J. Berman- Shirlee Snyder – Test Bank

$20.00

Description

INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Skills In Clinical Nursing  8th Edition by Audrey J. Berman- Shirlee Snyder – Test Bank

 

Sample  Questions

 

Exam
Name___________________________________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
1) The nurse is caring for a client who is on bedrest with bathroom privileges. While the client is in the
bathroom, the nurse changes the client’s bed and makes the bed in what way?
1)
A) Unoccupied open bed B) Occupied open bed
C) Unoccupied closed bed D) Surgical bed
Answer: A
Explanation: A) The bed is unoccupied, and the nurse would make an open bed, with the top
sheets folded back, so the bed is ready for the client to return to. An occupied bed
would be used if the client were unable to get out of bed. A closed bed is made
with the top covers over the entire bed to keep the bed clean when not in use. A
surgical bed would be made using extra materials in preparation for the returning
postoperative client.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The bed is unoccupied, and the nurse would make an open bed, with the top
sheets folded back, so the bed is ready for the client to return to. An occupied bed
would be used if the client were unable to get out of bed. A closed bed is made
with the top covers over the entire bed to keep the bed clean when not in use. A
surgical bed would be made using extra materials in preparation for the returning
postoperative client.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The bed is unoccupied, and the nurse would make an open bed, with the top
sheets folded back, so the bed is ready for the client to return to. An occupied bed
would be used if the client were unable to get out of bed. A closed bed is made
with the top covers over the entire bed to keep the bed clean when not in use. A
surgical bed would be made using extra materials in preparation for the returning
postoperative client.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The bed is unoccupied, and the nurse would make an open bed, with the top
sheets folded back, so the bed is ready for the client to return to. An occupied bed
would be used if the client were unable to get out of bed. A closed bed is made
with the top covers over the entire bed to keep the bed clean when not in use. A
surgical bed would be made using extra materials in preparation for the returning
postoperative client.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 6-1: Define the key terms used in the skill of bed-making.
1
2) The nurse is caring for a client in shock, and places the bed at an angle with the head lower than the
feet. This position is called the:
2)
A) Reverse Trendelenburg position. B) Trendelenburg position.
C) Fowler’s position. D) Semi-fowler’s position.
Answer: B
Explanation: A) The Trendelenburg position is used to place the head lower than the feet to
improve blood flow to the brain. Reverse Trendelenburg places the bed straight
but at an angle that puts the feet lower than the head. Fowler’s position raises the
head of bed into a 90-degree angle so the client is sitting upright. Semi-Fowler’s
raises the head of the bed approximately 45 degrees so the client’s head is upright
at a reclining angle.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The Trendelenburg position is used to place the head lower than the feet to
improve blood flow to the brain. Reverse Trendelenburg places the bed straight
but at an angle that puts the feet lower than the head. Fowler’s position raises the
head of bed into a 90-degree angle so the client is sitting upright. Semi-Fowler’s
raises the head of the bed approximately 45 degrees so the client’s head is upright
at a reclining angle.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The Trendelenburg position is used to place the head lower than the feet to
improve blood flow to the brain. Reverse Trendelenburg places the bed straight
but at an angle that puts the feet lower than the head. Fowler’s position raises the
head of bed into a 90-degree angle so the client is sitting upright. Semi-Fowler’s
raises the head of the bed approximately 45 degrees so the client’s head is upright
at a reclining angle.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The Trendelenburg position is used to place the head lower than the feet to
improve blood flow to the brain. Reverse Trendelenburg places the bed straight
but at an angle that puts the feet lower than the head. Fowler’s position raises the
head of bed into a 90-degree angle so the client is sitting upright. Semi-Fowler’s
raises the head of the bed approximately 45 degrees so the client’s head is upright
at a reclining angle.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 6-1: Define the key terms used in the skill of bed-making.
2
3) The nurse is providing the client with a hygienic and comfortable environment when performing
all of the following except:
3)
A) Speaking softly in the hall of the facility.
B) Obtaining a bed extender for the client who is very tall.
C) Placing a room deodorizer in the room of the client with asthma who complains of the odor in
the room.
D) Maintaining room temperature between 68 and 74°F.
Answer: C
Explanation: A) Deodorizers might be contraindicated for the client with respiratory disorders. All
of the other activities are supportive of the client’s environmental needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Deodorizers might be contraindicated for the client with respiratory disorders. All
of the other activities are supportive of the client’s environmental needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
C) Deodorizers might be contraindicated for the client with respiratory disorders. All
of the other activities are supportive of the client’s environmental needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Deodorizers might be contraindicated for the client with respiratory disorders. All
of the other activities are supportive of the client’s environmental needs.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 6-2: Describe the elements to consider when providing clients with a hygienic
and comfortable environment.
4) The nurse caring for an elderly man diagnosed with dementia bathes the client and changes the
wound dressing. Prior to leaving the room, the nurse should do which of the following?
4)
A) Raise the side rails.
B) Place the head of the bed in the semi-Fowler’s position.
C) Place the bed in the low position.
D) Remove the footboard from the bed.
Answer: C
Explanation: A) The nurse should return the bed to the low position to prevent injury to the client if
he attempts to get out of bed autonomously. Side rails are generally
contraindicated with most clients suffering from dementia because of the risk for
injury if they attempt to crawl over the rail. The position of the bed would be
determined by the time of day, activities the client will be performing, and client
preference. There would be no reason to remove the footboard from the bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
3
B) The nurse should return the bed to the low position to prevent injury to the client if
he attempts to get out of bed autonomously. Side rails are generally
contraindicated with most clients suffering from dementia because of the risk for
injury if they attempt to crawl over the rail. The position of the bed would be
determined by the time of day, activities the client will be performing, and client
preference. There would be no reason to remove the footboard from the bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) The nurse should return the bed to the low position to prevent injury to the client if
he attempts to get out of bed autonomously. Side rails are generally
contraindicated with most clients suffering from dementia because of the risk for
injury if they attempt to crawl over the rail. The position of the bed would be
determined by the time of day, activities the client will be performing, and client
preference. There would be no reason to remove the footboard from the bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) The nurse should return the bed to the low position to prevent injury to the client if
he attempts to get out of bed autonomously. Side rails are generally
contraindicated with most clients suffering from dementia because of the risk for
injury if they attempt to crawl over the rail. The position of the bed would be
determined by the time of day, activities the client will be performing, and client
preference. There would be no reason to remove the footboard from the bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 6-2: Describe the elements to consider when providing clients with a hygienic
and comfortable environment.
5) The nurse is caring for a client in respiratory distress. What would be the best bed position for this
client?
5)
A) Semi-Fowler’s position B) Trendelenburg position
C) Flat D) Fowler’s position
Answer: D
Explanation: A) The client with respiratory distress will breathe more easily if the bed is placed in
the Fowler’s position, because it reduces the compression of the abdominal
contents into the stomach and allows for full lung expansion. Semi-Fowler’s
position is the best choice if Fowler’s position is not possible due to the client’s
condition, but is not as good as Fowler’s because it still allows some intrusion of
abdominal contents into the diaphragm and limits full excursion. Trendelenburg
position would be contraindicated because this causes abdominal organs to press
into the diaphragm. Flat is also contraindicated, and will increase the client’s
respiratory distress.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
4
B) The client with respiratory distress will breathe more easily if the bed is placed in
the Fowler’s position, because it reduces the compression of the abdominal
contents into the stomach and allows for full lung expansion. Semi-Fowler’s
position is the best choice if Fowler’s position is not possible due to the client’s
condition, but is not as good as Fowler’s because it still allows some intrusion of
abdominal contents into the diaphragm and limits full excursion. Trendelenburg
position would be contraindicated because this causes abdominal organs to press
into the diaphragm. Flat is also contraindicated, and will increase the client’s
respiratory distress.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The client with respiratory distress will breathe more easily if the bed is placed in
the Fowler’s position, because it reduces the compression of the abdominal
contents into the stomach and allows for full lung expansion. Semi-Fowler’s
position is the best choice if Fowler’s position is not possible due to the client’s
condition, but is not as good as Fowler’s because it still allows some intrusion of
abdominal contents into the diaphragm and limits full excursion. Trendelenburg
position would be contraindicated because this causes abdominal organs to press
into the diaphragm. Flat is also contraindicated, and will increase the client’s
respiratory distress.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The client with respiratory distress will breathe more easily if the bed is placed in
the Fowler’s position, because it reduces the compression of the abdominal
contents into the stomach and allows for full lung expansion. Semi-Fowler’s
position is the best choice if Fowler’s position is not possible due to the client’s
condition, but is not as good as Fowler’s because it still allows some intrusion of
abdominal contents into the diaphragm and limits full excursion. Trendelenburg
position would be contraindicated because this causes abdominal organs to press
into the diaphragm. Flat is also contraindicated, and will increase the client’s
respiratory distress.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 6-3: Identify indications for common bed positions.
6) The nurse caring for a client with fractured third cervical vertebrae determines the client is in spinal
shock. How would the nurse best position the bed?
6)
A) Flat B) Semi-Fowler’s
C) Trendelenburg D) Reverse Trendelenburg
Answer: A
Explanation: A) A client with a fractured cervical vertebra must be maintained in a flat position to
prevent any movement of the neck. Placing the client into the Trendelenburg
position, which would normally be indicated for a client in shock, would put this
client at risk for further damage to the spinal cord. Semi-Fowler position is
contraindicated due to the client’s spinal injury, and the reverse Trendelenburg
position is contraindicated due to the client’s diagnosis of spinal shock.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
5
B) A client with a fractured cervical vertebra must be maintained in a flat position to
prevent any movement of the neck. Placing the client into the Trendelenburg
position, which would normally be indicated for a client in shock, would put this
client at risk for further damage to the spinal cord. Semi-Fowler position is
contraindicated due to the client’s spinal injury, and the reverse Trendelenburg
position is contraindicated due to the client’s diagnosis of spinal shock.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) A client with a fractured cervical vertebra must be maintained in a flat position to
prevent any movement of the neck. Placing the client into the Trendelenburg
position, which would normally be indicated for a client in shock, would put this
client at risk for further damage to the spinal cord. Semi-Fowler position is
contraindicated due to the client’s spinal injury, and the reverse Trendelenburg
position is contraindicated due to the client’s diagnosis of spinal shock.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) A client with a fractured cervical vertebra must be maintained in a flat position to
prevent any movement of the neck. Placing the client into the Trendelenburg
position, which would normally be indicated for a client in shock, would put this
client at risk for further damage to the spinal cord. Semi-Fowler position is
contraindicated due to the client’s spinal injury, and the reverse Trendelenburg
position is contraindicated due to the client’s diagnosis of spinal shock.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 6-3: Identify indications for common bed positions.
6
7) The nurse delegates bed making to the unlicensed assistive personnel except for which of the
following clients, whose bed should be made by the nurse?
7)
A) The postoperative client diagnosed with dementia on complete bedrest
B) The client who is diagnosed with myocardial infarction who has bathroom privileges
C) The client with increased intracranial pressure on complete bedrest
D) The postoperative client
Answer: C
Explanation: A) The client with increased intracranial pressure will generally have an increase in
pressure with any activity or movement, so the nurse should change this client’s
bed, although the unlicensed assistive personnel could assist the nurse. The other
clients’ beds could be safely delegated to the unlicensed assistive personnel.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
B) The client with increased intracranial pressure will generally have an increase in
pressure with any activity or movement, so the nurse should change this client’s
bed, although the unlicensed assistive personnel could assist the nurse. The other
clients’ beds could be safely delegated to the unlicensed assistive personnel.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
C) The client with increased intracranial pressure will generally have an increase in
pressure with any activity or movement, so the nurse should change this client’s
bed, although the unlicensed assistive personnel could assist the nurse. The other
clients’ beds could be safely delegated to the unlicensed assistive personnel.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
D) The client with increased intracranial pressure will generally have an increase in
pressure with any activity or movement, so the nurse should change this client’s
bed, although the unlicensed assistive personnel could assist the nurse. The other
clients’ beds could be safely delegated to the unlicensed assistive personnel.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
Objective: Learning Outcome 6-4: Recognize when it is appropriate to delegate bed-making to unlicensed
assistive personnel.
8) When delegating bed making to the unlicensed assistive personnel (UAP), the nurse would instruct
the UAP on which of the following? Select all that apply.
8)
A) Proper disposal of linens that contain drainage
B) What tubes or dressings the client might have
C) How to make hospital corners
D) Whom to inform if they notice anything unusual
E) Placing the call bell in a specific location for a client with mobility concerns
Answer: A, B, E
7
Explanation: A) The nurse should instruct the UAP on how to dispose of linens that contain
drainage, and should inform him of any tubes or dressings the client may have in
place and the importance of placing the call bell in a specific location for a client
with mobility concerns. The nurse should not have to teach the UAP how to make
a bed, because he already should be familiar with the procedure. There is no need
to inform the UAP whom to notify because the UAP should inform the nurse if
anything unusual occurs.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) The nurse should instruct the UAP on how to dispose of linens that contain
drainage, and should inform him of any tubes or dressings the client may have in
place and the importance of placing the call bell in a specific location for a client
with mobility concerns. The nurse should not have to teach the UAP how to make
a bed, because he already should be familiar with the procedure. There is no need
to inform the UAP whom to notify because the UAP should inform the nurse if
anything unusual occurs.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) The nurse should instruct the UAP on how to dispose of linens that contain
drainage, and should inform him of any tubes or dressings the client may have in
place and the importance of placing the call bell in a specific location for a client
with mobility concerns. The nurse should not have to teach the UAP how to make
a bed, because he already should be familiar with the procedure. There is no need
to inform the UAP whom to notify because the UAP should inform the nurse if
anything unusual occurs.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) The nurse should instruct the UAP on how to dispose of linens that contain
drainage, and should inform him of any tubes or dressings the client may have in
place and the importance of placing the call bell in a specific location for a client
with mobility concerns. The nurse should not have to teach the UAP how to make
a bed, because he already should be familiar with the procedure. There is no need
to inform the UAP whom to notify because the UAP should inform the nurse if
anything unusual occurs.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
E) The nurse should instruct the UAP on how to dispose of linens that contain
drainage, and should inform him of any tubes or dressings the client may have in
place and the importance of placing the call bell in a specific location for a client
with mobility concerns. The nurse should not have to teach the UAP how to make
a bed, because he already should be familiar with the procedure. There is no need
to inform the UAP whom to notify because the UAP should inform the nurse if
anything unusual occurs.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 6-4: Recognize when it is appropriate to delegate bed-making to unlicensed
assistive personnel.
8
9) The nurse is making beds on the medical surgical unit. What would the nurse do differently when
making a surgical bed versus an open unoccupied bed? Select all that apply.
9)
A) Strip the bed.
B) Do not tuck, miter, or toe-pleat the top covers.
C) Fold top sheets into a triangle at the side of the bed.
D) Place pillows on the chair beside the bed.
E) Raise the bed to a comfortable working height.
Answer: B, C, D
Explanation: A) When making a surgical bed, the top covers would not be tucked, mitered, or
pleated, but rather folded to the side of the bed, forming a triangle so the bed is
prepared for the client to slide from the cart to the bed. Pillows are removed from
the bed and placed in the chair at the side of the bed because they will be in the
way when the client is transferred from the stretcher. The bed should always be
raised to a comfortable working height to avoid back strain for the nurse when
making a bed, and the old linen should be stripped prior to making the fresh bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) When making a surgical bed, the top covers would not be tucked, mitered, or
pleated, but rather folded to the side of the bed, forming a triangle so the bed is
prepared for the client to slide from the cart to the bed. Pillows are removed from
the bed and placed in the chair at the side of the bed because they will be in the
way when the client is transferred from the stretcher. The bed should always be
raised to a comfortable working height to avoid back strain for the nurse when
making a bed, and the old linen should be stripped prior to making the fresh bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) When making a surgical bed, the top covers would not be tucked, mitered, or
pleated, but rather folded to the side of the bed, forming a triangle so the bed is
prepared for the client to slide from the cart to the bed. Pillows are removed from
the bed and placed in the chair at the side of the bed because they will be in the
way when the client is transferred from the stretcher. The bed should always be
raised to a comfortable working height to avoid back strain for the nurse when
making a bed, and the old linen should be stripped prior to making the fresh bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) When making a surgical bed, the top covers would not be tucked, mitered, or
pleated, but rather folded to the side of the bed, forming a triangle so the bed is
prepared for the client to slide from the cart to the bed. Pillows are removed from
the bed and placed in the chair at the side of the bed because they will be in the
way when the client is transferred from the stretcher. The bed should always be
raised to a comfortable working height to avoid back strain for the nurse when
making a bed, and the old linen should be stripped prior to making the fresh bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
9
E) When making a surgical bed, the top covers would not be tucked, mitered, or
pleated, but rather folded to the side of the bed, forming a triangle so the bed is
prepared for the client to slide from the cart to the bed. Pillows are removed from
the bed and placed in the chair at the side of the bed because they will be in the
way when the client is transferred from the stretcher. The bed should always be
raised to a comfortable working height to avoid back strain for the nurse when
making a bed, and the old linen should be stripped prior to making the fresh bed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 6-5: Verbalize the steps used to make a:
A. Closed and open unoccupied bed.
B. Surgical bed.
C. Occupied bed.
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
10) The nurse is making an occupied bed for a client who is required to maintain complete
bedrest. Place the following steps in the proper order to be performed.
1. Loosen the bottom soiled linens behind the side-lying client and fan-fold them close
to the client.
2. Pull linens from the center of the bed and make that side of the bed.
3. Make the side of the bed behind the client and tuck sheets under the client.
4. Position the client supine and place clean top linen on the bed.
5. Remove the soiled linen from the bed.
10)
Answer: 1, 3, 5, 2, 4
Explanation: The nurse removes top bedding, and may cover the client with the top sheet or a
bath blanket. Raise the side rail on the side the client will roll toward, help the
client roll, and then loosen the lower linen on the side behind the client.
Fan-fold soiled linen toward the client, apply fresh linen, and tuck under the
mattress, fan-folding the clean linen toward the center of the bed. Pull the side
rail up on that side of the bed and assist the client to roll over the linen in the
center of the bed. Move to the other side of the bed, lowering the side rail, and
remove the soiled linen. Once the soiled linen is removed, the fresh linen can be
pulled over the bed and tucked under the mattress. The client now can be
positioned supine, and fresh top sheets can be applied, removing the bath
blanket or sheet covering the client by pulling it out from under the clean top
linen. Position the client for comfort, place the bed in the low position, and
make sure the call bell is conveniently located.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 6-5: Verbalize the steps used to make a:
A. Closed and open unoccupied bed.
B. Surgical bed.
C. Occupied bed.
Exam
Name___________________________________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
1) The nurse performs hand hygiene to prevent all of the following except: 1)
A) Vehicle-borne transmission. B) Vector-borne transmission.
C) Indirect contact transmission. D) Direct contact transmission
Answer: B
Explanation: A) Vector-borne transmission of organisms pertains to an animal or insect that serves
as an immediate means of transporting the infectious agent, and so could not be
prevented by hand hygiene. Vehicle-borne transmission pertains to any substance
that transfers infectious agents to a susceptible host, such as the nurse’s hands.
Vehicle-borne transmission is a form of indirect contact transmission. Direct
contact transmission is transmission of a microorganism through touching,
kissing, or any form of direct contact, such as the nurse touching the client who is
susceptible to infection.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
B) Vector-borne transmission of organisms pertains to an animal or insect that serves
as an immediate means of transporting the infectious agent, and so could not be
prevented by hand hygiene. Vehicle-borne transmission pertains to any substance
that transfers infectious agents to a susceptible host, such as the nurse’s hands.
Vehicle-borne transmission is a form of indirect contact transmission. Direct
contact transmission is transmission of a microorganism through touching,
kissing, or any form of direct contact, such as the nurse touching the client who is
susceptible to infection.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
C) Vector-borne transmission of organisms pertains to an animal or insect that serves
as an immediate means of transporting the infectious agent, and so could not be
prevented by hand hygiene. Vehicle-borne transmission pertains to any substance
that transfers infectious agents to a susceptible host, such as the nurse’s hands.
Vehicle-borne transmission is a form of indirect contact transmission. Direct
contact transmission is transmission of a microorganism through touching,
kissing, or any form of direct contact, such as the nurse touching the client who is
susceptible to infection.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
1
D) Vector-borne transmission of organisms pertains to an animal or insect that serves
as an immediate means of transporting the infectious agent, and so could not be
prevented by hand hygiene. Vehicle-borne transmission pertains to any substance
that transfers infectious agents to a susceptible host, such as the nurse’s hands.
Vehicle-borne transmission is a form of indirect contact transmission. Direct
contact transmission is transmission of a microorganism through touching,
kissing, or any form of direct contact, such as the nurse touching the client who is
susceptible to infection.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
Objective: Learning Outcome 7-1: Define the key terms used in infection control skills.
2) The nurse uses a substance to destroy microorganisms other than spores. Which of the following
terms describes this substance?
2)
A) Antiseptic B) Disinfectant C) Sterilizer D) Aseptic
Answer: B
Explanation: A) The substance that kills microorganisms except for spores is a disinfectant. An
antiseptic destroys some microorganisms. Sterilization is complete removal of all
pathogens. Aseptic means free from infection or infectious material.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) The substance that kills microorganisms except for spores is a disinfectant. An
antiseptic destroys some microorganisms. Sterilization is complete removal of all
pathogens. Aseptic means free from infection or infectious material.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) The substance that kills microorganisms except for spores is a disinfectant. An
antiseptic destroys some microorganisms. Sterilization is complete removal of all
pathogens. Aseptic means free from infection or infectious material.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) The substance that kills microorganisms except for spores is a disinfectant. An
antiseptic destroys some microorganisms. Sterilization is complete removal of all
pathogens. Aseptic means free from infection or infectious material.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 7-1: Define the key terms used in infection control skills.
3) The nurse would break the chain of infection by eliminating the reservoir when performing which
of the following interventions?
3)
A) Ensure that all antibiotics are taken properly and only when needed, to avoid creation of
antibiotic resistant microorganisms.
B) Avoid coughing or sneezing without covering the mouth.
C) Use sterile technique for invasive procedures.
D) Change dressings and bandages when they are soiled or wet.
Answer: D
2
Explanation: A) Moist dressings create ideal reservoirs for the growth of microorganisms. Ensuring
antibiotics are taken properly breaks the chain by reducing growth of new etiologic
agents. Covering the mouth when coughing or sneezing reduces the portal of exit,
while following sterile technique for invasive procedures reduces the portal of
entry.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Moist dressings create ideal reservoirs for the growth of microorganisms. Ensuring
antibiotics are taken properly breaks the chain by reducing growth of new etiologic
agents. Covering the mouth when coughing or sneezing reduces the portal of exit,
while following sterile technique for invasive procedures reduces the portal of
entry.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) Moist dressings create ideal reservoirs for the growth of microorganisms. Ensuring
antibiotics are taken properly breaks the chain by reducing growth of new etiologic
agents. Covering the mouth when coughing or sneezing reduces the portal of exit,
while following sterile technique for invasive procedures reduces the portal of
entry.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Moist dressings create ideal reservoirs for the growth of microorganisms. Ensuring
antibiotics are taken properly breaks the chain by reducing growth of new etiologic
agents. Covering the mouth when coughing or sneezing reduces the portal of exit,
while following sterile technique for invasive procedures reduces the portal of
entry.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 7-2: Describe six links in the chain of infection.
3
4) When the nurse performs hand hygiene properly, the nurse breaks what aspect in the chain of
infection?
4)
A) Portal of entry B) Portal of exit
C) Method of transmission D) Etiological agent
Answer: C
Explanation: A) Hand hygiene breaks the method of transmission by reducing the pathogens on
the hands when touching clients or objects that come in contact with clients. Portal
of entry is the opening that allows pathogens to invade the body, portal of exit is
the means of expelling pathogens from the body, and the etiological agent is the
pathogen.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Hand hygiene breaks the method of transmission by reducing the pathogens on
the hands when touching clients or objects that come in contact with clients. Portal
of entry is the opening that allows pathogens to invade the body, portal of exit is
the means of expelling pathogens from the body, and the etiological agent is the
pathogen.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) Hand hygiene breaks the method of transmission by reducing the pathogens on
the hands when touching clients or objects that come in contact with clients. Portal
of entry is the opening that allows pathogens to invade the body, portal of exit is
the means of expelling pathogens from the body, and the etiological agent is the
pathogen.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Hand hygiene breaks the method of transmission by reducing the pathogens on
the hands when touching clients or objects that come in contact with clients. Portal
of entry is the opening that allows pathogens to invade the body, portal of exit is
the means of expelling pathogens from the body, and the etiological agent is the
pathogen.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 7-2: Describe six links in the chain of infection.
5) Which of the following interventions could be safely delegated to the unlicensed assistive
personnel?
5)
A) Setting up a sterile tray
B) Adding wrapped supplies to a sterile field
C) Tying the nurse’s sterile gown in back
D) Observing the sterile field to prevent contamination when the nurse must leave the room
Answer: D
4
Explanation: A) The unlicensed assistive personnel (UAP) could be allowed to observe the sterile
field, making sure no one gets near it, while the nurse leaves the room. The nurse
cannot safely delegate anything connected with setting up or adding to a sterile
field, or maintaining sterility of the gown while grabbing and tying the belt. Sterile
technique is never delegated to the UAP.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
B) The unlicensed assistive personnel (UAP) could be allowed to observe the sterile
field, making sure no one gets near it, while the nurse leaves the room. The nurse
cannot safely delegate anything connected with setting up or adding to a sterile
field, or maintaining sterility of the gown while grabbing and tying the belt. Sterile
technique is never delegated to the UAP.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
C) The unlicensed assistive personnel (UAP) could be allowed to observe the sterile
field, making sure no one gets near it, while the nurse leaves the room. The nurse
cannot safely delegate anything connected with setting up or adding to a sterile
field, or maintaining sterility of the gown while grabbing and tying the belt. Sterile
technique is never delegated to the UAP.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
D) The unlicensed assistive personnel (UAP) could be allowed to observe the sterile
field, making sure no one gets near it, while the nurse leaves the room. The nurse
cannot safely delegate anything connected with setting up or adding to a sterile
field, or maintaining sterility of the gown while grabbing and tying the belt. Sterile
technique is never delegated to the UAP.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
Objective: Learning Outcome 7-3: Recognize when it is appropriate to delegate infection control skills to
unlicensed assistive personnel.
6) The nurse is setting up a sterile tray for the physician who will insert a central venous access
device. While the nurse completes setting up the tray, the unit secretary enters the room to inform
the nurse the physician has been delayed, and will not arrive for 15-20 minutes. The nurse’s best
action would be to:
6)
A) Sit in the room talking with the client while observing the sterile field is not contaminated.
B) Discard the sterile tray and obtain a new one to set up when the physician arrives.
C) Cover the sterile field with a sterile drape and set the tray out of the way for use when the
physician arrives.
D) Leave the tray where it is and return when the physician arrives.
Answer: C
5
Explanation: A) The nurse should cover the sterile field with a sterile drape or towel and move the
tray on which the sterile field was prepared to a place where it is not likely to be
bumped or touched. While sitting in the room observing the sterile tray would be
the ideal implementation, it would not be effective time management. Discarding
the sterile tray would not be cost-effective, and is unnecessary. Leaving the tray
uncovered would be dangerous if the nurse is not in the room because it is
impossible to tell if the tray is still sterile merely by looking at it.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The nurse should cover the sterile field with a sterile drape or towel and move the
tray on which the sterile field was prepared to a place where it is not likely to be
bumped or touched. While sitting in the room observing the sterile tray would be
the ideal implementation, it would not be effective time management. Discarding
the sterile tray would not be cost-effective, and is unnecessary. Leaving the tray
uncovered would be dangerous if the nurse is not in the room because it is
impossible to tell if the tray is still sterile merely by looking at it.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The nurse should cover the sterile field with a sterile drape or towel and move the
tray on which the sterile field was prepared to a place where it is not likely to be
bumped or touched. While sitting in the room observing the sterile tray would be
the ideal implementation, it would not be effective time management. Discarding
the sterile tray would not be cost-effective, and is unnecessary. Leaving the tray
uncovered would be dangerous if the nurse is not in the room because it is
impossible to tell if the tray is still sterile merely by looking at it.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The nurse should cover the sterile field with a sterile drape or towel and move the
tray on which the sterile field was prepared to a place where it is not likely to be
bumped or touched. While sitting in the room observing the sterile tray would be
the ideal implementation, it would not be effective time management. Discarding
the sterile tray would not be cost-effective, and is unnecessary. Leaving the tray
uncovered would be dangerous if the nurse is not in the room because it is
impossible to tell if the tray is still sterile merely by looking at it.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 7-4: Verbalize the steps used in:
A. Establishing and maintaining a sterile field.
B. Applying and removing sterile gloves.
C. Implementing transmission-based precautions, including bagging articles and managing
equipment used for isolation clients.
7) When the nurse dons sterile gloves, which of the following would demonstrate correct technique? 7)
A) Straighten the cuff of the first glove with the ungloved hand.
B) When donning the gloves, put the first glove on the nondominant hand.
C) Pick up the second glove by sliding the gloved fingers under the fold of the glove and sliding
the hand into the opening.
D) If the sterile glove is punctured, pull a new sterile glove on top of the old glove.
Answer: C
6
Explanation: A) The nurse puts the first glove on the nondominant hand, and then slides the gloved
finger under the cuff of the second glove, taking care to keep the sterile gloved
hand as far away from the ungloved hand as possible to avoid contamination.
Only after both gloves are on is the cuff of the first glove straightened by sliding
the gloved dominant hand under the cuff, using care not to touch the
contaminated underside of the glove. If the sterile glove is punctured, both gloves
must be removed, hand hygiene should be performed, and then the nurse should
reglove.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The nurse puts the first glove on the nondominant hand, and then slides the gloved
finger under the cuff of the second glove, taking care to keep the sterile gloved
hand as far away from the ungloved hand as possible to avoid contamination.
Only after both gloves are on is the cuff of the first glove straightened by sliding
the gloved dominant hand under the cuff, using care not to touch the
contaminated underside of the glove. If the sterile glove is punctured, both gloves
must be removed, hand hygiene should be performed, and then the nurse should
reglove.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The nurse puts the first glove on the nondominant hand, and then slides the gloved
finger under the cuff of the second glove, taking care to keep the sterile gloved
hand as far away from the ungloved hand as possible to avoid contamination.
Only after both gloves are on is the cuff of the first glove straightened by sliding
the gloved dominant hand under the cuff, using care not to touch the
contaminated underside of the glove. If the sterile glove is punctured, both gloves
must be removed, hand hygiene should be performed, and then the nurse should
reglove.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The nurse puts the first glove on the nondominant hand, and then slides the gloved
finger under the cuff of the second glove, taking care to keep the sterile gloved
hand as far away from the ungloved hand as possible to avoid contamination.
Only after both gloves are on is the cuff of the first glove straightened by sliding
the gloved dominant hand under the cuff, using care not to touch the
contaminated underside of the glove. If the sterile glove is punctured, both gloves
must be removed, hand hygiene should be performed, and then the nurse should
reglove.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 7-4: Verbalize the steps used in:
A. Establishing and maintaining a sterile field.
B. Applying and removing sterile gloves.
C. Implementing transmission-based precautions, including bagging articles and managing
equipment used for isolation clients.
7
8) The nurse is discharging the client who required contact-based transmission precautions. What
should the nurse do with the equipment that is not disposable found in the room?
8)
A) Tell the cleaning staff to double-bag the equipment.
B) Sterilize the equipment before removing it from the room.
C) Place contaminated items in an impermeable bag and send to be decontaminated.
D) Place contaminated items in a paper bag and take to the dirty utility room.
Answer: C
Explanation: A) The equipment should be placed in an impermeable bag that will not allow
pathogens to leak, and sent to the proper area for decontamination. This should not
be delegated to the cleaning staff in most facilities, because they are not trained in
transmission prevention. It would not be possible to sterilize equipment before
removing it from the room, because rooms are not equipped with all the
specialized machines required to sterilize all equipment. Placing contaminated
items in a paper bag would not prevent leakage of pathogens from the bag.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) The equipment should be placed in an impermeable bag that will not allow
pathogens to leak, and sent to the proper area for decontamination. This should not
be delegated to the cleaning staff in most facilities, because they are not trained in
transmission prevention. It would not be possible to sterilize equipment before
removing it from the room, because rooms are not equipped with all the
specialized machines required to sterilize all equipment. Placing contaminated
items in a paper bag would not prevent leakage of pathogens from the bag.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) The equipment should be placed in an impermeable bag that will not allow
pathogens to leak, and sent to the proper area for decontamination. This should not
be delegated to the cleaning staff in most facilities, because they are not trained in
transmission prevention. It would not be possible to sterilize equipment before
removing it from the room, because rooms are not equipped with all the
specialized machines required to sterilize all equipment. Placing contaminated
items in a paper bag would not prevent leakage of pathogens from the bag.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) The equipment should be placed in an impermeable bag that will not allow
pathogens to leak, and sent to the proper area for decontamination. This should not
be delegated to the cleaning staff in most facilities, because they are not trained in
transmission prevention. It would not be possible to sterilize equipment before
removing it from the room, because rooms are not equipped with all the
specialized machines required to sterilize all equipment. Placing contaminated
items in a paper bag would not prevent leakage of pathogens from the bag.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 7-4: Verbalize the steps used in:
A. Establishing and maintaining a sterile field.
B. Applying and removing sterile gloves.
C. Implementing transmission-based precautions, including bagging articles and managing
equipment used for isolation clients.
8
9) The nurse recognizes the difference between standard precautions and transmission-based
isolation precaution systems is:
9)
A) Standard precautions protect the nurse, while transmission-based precautions protect the
client.
B) Standard precautions require the use of clean gloves, while transmission-based precautions
require the use of sterile gloves.
C) Standard precautions are used in addition to transmission-based precautions when standard
precautions would not completely block the chain of infection.
D) Transmission-based precautions block the chain of infection, while standard precautions
protect the nurse but do not block the chain of infection.
Answer: C
Explanation: A) Standard precautions are used in addition to, not in place of, transmission-based
precautions. Both standard and transmission-based precautions are used to protect
the nurse, the client, and all others who are on the unit. Sterile gloves are not
required for either form of precaution, and would be used for invasive procedures
no matter what other types of precautions are in place. Both forms of precaution
block the chain of infection, but some diagnoses or conditions require additional
protection in the form of transmission-based precautions.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
B) Standard precautions are used in addition to, not in place of, transmission-based
precautions. Both standard and transmission-based precautions are used to protect
the nurse, the client, and all others who are on the unit. Sterile gloves are not
required for either form of precaution, and would be used for invasive procedures
no matter what other types of precautions are in place. Both forms of precaution
block the chain of infection, but some diagnoses or conditions require additional
protection in the form of transmission-based precautions.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
C) Standard precautions are used in addition to, not in place of, transmission-based
precautions. Both standard and transmission-based precautions are used to protect
the nurse, the client, and all others who are on the unit. Sterile gloves are not
required for either form of precaution, and would be used for invasive procedures
no matter what other types of precautions are in place. Both forms of precaution
block the chain of infection, but some diagnoses or conditions require additional
protection in the form of transmission-based precautions.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
D) Standard precautions are used in addition to, not in place of, transmission-based
precautions. Both standard and transmission-based precautions are used to protect
the nurse, the client, and all others who are on the unit. Sterile gloves are not
required for either form of precaution, and would be used for invasive procedures
no matter what other types of precautions are in place. Both forms of precaution
block the chain of infection, but some diagnoses or conditions require additional
protection in the form of transmission-based precautions.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 7-5: Compare and contrast standard precautions and transmission-based
isolation precaution systems.
9
10) The nurse is documenting in the medical record of a client requiring protective precautions. What
would the nurse document?
10)
A) Type of protective precautions taken
B) Use of clean gloves when changing wound dressing
C) Use of a mask when client requires droplet precautions
D) Performance of hand hygiene
Answer: A
Explanation: A) There is no need to document use of personal protective equipment such as gloves
or mask, as this is routine care when a client is in specific forms of protective
isolation. However, the nurse should document what form of protective
precautions is being observed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) There is no need to document use of personal protective equipment such as gloves
or mask, as this is routine care when a client is in specific forms of protective
isolation. However, the nurse should document what form of protective
precautions is being observed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) There is no need to document use of personal protective equipment such as gloves
or mask, as this is routine care when a client is in specific forms of protective
isolation. However, the nurse should document what form of protective
precautions is being observed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) There is no need to document use of personal protective equipment such as gloves
or mask, as this is routine care when a client is in specific forms of protective
isolation. However, the nurse should document what form of protective
precautions is being observed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 7-6: Demonstrate appropriate documentation and reporting of infection control
skills.
Exam
Name___________________________________
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
1) The client with a sprained ankle is complaining of pain in the injured area. The nurse would
classify this pain most specifically as:
1)
A) Visceral pain. B) Somatic pain.
C) Physiologic pain. D) Neuropathic pain.
Answer: B
Explanation: A) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would
best describe this client’s pain. Somatic pain is a subclassification of physiological
pain, so it would be less specific to call it physiological as opposed to somatic.
Visceral pain tends to be poorly located, resulting from activation of pain receptors
in the organs and/or hollow viscera. Neuropathic pain results from damaged or
malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
B) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would
best describe this client’s pain. Somatic pain is a subclassification of physiological
pain, so it would be less specific to call it physiological as opposed to somatic.
Visceral pain tends to be poorly located, resulting from activation of pain receptors
in the organs and/or hollow viscera. Neuropathic pain results from damaged or
malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
C) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would
best describe this client’s pain. Somatic pain is a subclassification of physiological
pain, so it would be less specific to call it physiological as opposed to somatic.
Visceral pain tends to be poorly located, resulting from activation of pain receptors
in the organs and/or hollow viscera. Neuropathic pain results from damaged or
malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
D) Somatic pain originates in the skin, muscles, bone, or connective tissue, and would
best describe this client’s pain. Somatic pain is a subclassification of physiological
pain, so it would be less specific to call it physiological as opposed to somatic.
Visceral pain tends to be poorly located, resulting from activation of pain receptors
in the organs and/or hollow viscera. Neuropathic pain results from damaged or
malfunctioning nerves.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-1: Define the key terms used in the skills of pain management.
1
2) The nurse documents the maximum amount of pain the client can tolerate as: 2)
A) Pain threshold. B) Hyperalgesia. C) Pain tolerance. D) Allodynia.
Answer: C
Explanation: A) Pain tolerance is the maximum amount of pain a client can tolerate. Pain
threshold is the lowest amount of stimuli needed for a person to label a sensation
as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful
stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of
wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Pain tolerance is the maximum amount of pain a client can tolerate. Pain
threshold is the lowest amount of stimuli needed for a person to label a sensation
as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful
stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of
wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
C) Pain tolerance is the maximum amount of pain a client can tolerate. Pain
threshold is the lowest amount of stimuli needed for a person to label a sensation
as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful
stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of
wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Pain tolerance is the maximum amount of pain a client can tolerate. Pain
threshold is the lowest amount of stimuli needed for a person to label a sensation
as pain. Hyperalgesia, or hyperpathia, denotes a heightened response to painful
stimuli. Allodynia is pain produced by nonpainful stimuli, such as the touch of
wind to the area.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-1: Define the key terms used in the skills of pain management.
2
3) The nurse is using nonpharmacological methods to manage a client’s pain, and applies a unit that
applies low-voltage electrical stimulation directly over the pain areas specifically known as:
3)
A) TENS unit. B) Nerve block.
C) Functional restoration. D) Cutaneous stimulation.
Answer: A
Explanation: A) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator,
which is a form of cutaneous stimulation. However, TENS would be the specific
name of this treatment, while cutaneous stimulation would be a more general
term. Nerve block is a pharmacological treatment injecting an analgesic or steroid
into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator,
which is a form of cutaneous stimulation. However, TENS would be the specific
name of this treatment, while cutaneous stimulation would be a more general
term. Nerve block is a pharmacological treatment injecting an analgesic or steroid
into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator,
which is a form of cutaneous stimulation. However, TENS would be the specific
name of this treatment, while cutaneous stimulation would be a more general
term. Nerve block is a pharmacological treatment injecting an analgesic or steroid
into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The unit described is a TENS unit, or transcutaneous electrical nerve stimulator,
which is a form of cutaneous stimulation. However, TENS would be the specific
name of this treatment, while cutaneous stimulation would be a more general
term. Nerve block is a pharmacological treatment injecting an analgesic or steroid
into the site of pain. Functional restoration is a form of social therapy.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-1: Define the key terms used in the skills of pain management.
3
4) The client has pain in the lower back that radiates down the leg as the result of a herniated disk
compressing the sciatic nerve that began four months ago. This pain would be described as:
4)
A) Acute somatic pain. B) Acute visceral pain.
C) Chronic neuropathic pain. D) Acute neuropathic pain.
Answer: D
Explanation: A) The pain is considered acute because it has lasted less than six months, which is the
NANDA-accepted definition of chronic pain. It is neuropathic pain because it is
caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
B) The pain is considered acute because it has lasted less than six months, which is the
NANDA-accepted definition of chronic pain. It is neuropathic pain because it is
caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
C) The pain is considered acute because it has lasted less than six months, which is the
NANDA-accepted definition of chronic pain. It is neuropathic pain because it is
caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
D) The pain is considered acute because it has lasted less than six months, which is the
NANDA-accepted definition of chronic pain. It is neuropathic pain because it is
caused by damage to the sciatic nerve.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-2: Describe the various types of pain.
5) The nurse working on the labor and delivery unit has noticed how differently each client responds
to the pain associated with labor. The nurse recognizes this is most likely due to: (Select all that
apply.)
5)
A) Ethnic and cultural values.
B) Developmental stage.
C) Past experience with pain.
D) Physiological functioning of the brain.
E) Meaning of pain.
Answer: A, B, C, E
Explanation: A) Clients with different ethnic and cultural values are socialized to respond to pain
in different manners. The developmental stage determines the client’s ability to
cope and report the pain. Past experience, including the effectiveness of the
treatment plan in the past, with pain will have an impact on how the client deals
with pain. Pain has different meaning to different clients, with some clients
believing it is a punishment from a higher power or an opportunity to show how
strong they are. Physiological functioning affects how pain is felt but does not
affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
4
B) Clients with different ethnic and cultural values are socialized to respond to pain
in different manners. The developmental stage determines the client’s ability to
cope and report the pain. Past experience, including the effectiveness of the
treatment plan in the past, with pain will have an impact on how the client deals
with pain. Pain has different meaning to different clients, with some clients
believing it is a punishment from a higher power or an opportunity to show how
strong they are. Physiological functioning affects how pain is felt but does not
affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
C) Clients with different ethnic and cultural values are socialized to respond to pain
in different manners. The developmental stage determines the client’s ability to
cope and report the pain. Past experience, including the effectiveness of the
treatment plan in the past, with pain will have an impact on how the client deals
with pain. Pain has different meaning to different clients, with some clients
believing it is a punishment from a higher power or an opportunity to show how
strong they are. Physiological functioning affects how pain is felt but does not
affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
D) Clients with different ethnic and cultural values are socialized to respond to pain
in different manners. The developmental stage determines the client’s ability to
cope and report the pain. Past experience, including the effectiveness of the
treatment plan in the past, with pain will have an impact on how the client deals
with pain. Pain has different meaning to different clients, with some clients
believing it is a punishment from a higher power or an opportunity to show how
strong they are. Physiological functioning affects how pain is felt but does not
affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
E) Clients with different ethnic and cultural values are socialized to respond to pain
in different manners. The developmental stage determines the client’s ability to
cope and report the pain. Past experience, including the effectiveness of the
treatment plan in the past, with pain will have an impact on how the client deals
with pain. Pain has different meaning to different clients, with some clients
believing it is a punishment from a higher power or an opportunity to show how
strong they are. Physiological functioning affects how pain is felt but does not
affect the pain experience.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-3: Describe factors that affect the pain experience.
6) The nurse is caring for a preschool-aged child who is in pain secondary to a compound fracture
resulting from a motor vehicle crash. The nurse recognizes which of the following are true? Select
all that apply.
6)
A) It is best for the nurse to reason with the child in managing the pain.
B) The child will often respond with crying and anger because he perceives pain as a threat to
security.
C) Try to avoid touching or holding the child to reduce the level of pain.
5
D) Appeal to the child’s belief in magic by using a magic blanket to take away pain.
E) The child might consider pain a punishment for previous misbehaviors.
Answer: B, D, E
Explanation: A) The preschool-aged child does not have the vocabulary or logic skills to perceive
pain as a physiological response, so he will often respond with crying and anger
because he sees the pain as threatening his security. A child at this stage of
development has a strong belief in magic, which can be used as a pain
management tool. Children often perceive pain as a punishment, so it is important
for the nurse to reassure the child that it is not his fault. It is not possible to reason
with a child at this stage of development, because he does not have the necessary
cognitive ability. Holding and comforting the child is a useful pain management
tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
B) The preschool-aged child does not have the vocabulary or logic skills to perceive
pain as a physiological response, so he will often respond with crying and anger
because he sees the pain as threatening his security. A child at this stage of
development has a strong belief in magic, which can be used as a pain
management tool. Children often perceive pain as a punishment, so it is important
for the nurse to reassure the child that it is not his fault. It is not possible to reason
with a child at this stage of development, because he does not have the necessary
cognitive ability. Holding and comforting the child is a useful pain management
tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
C) The preschool-aged child does not have the vocabulary or logic skills to perceive
pain as a physiological response, so he will often respond with crying and anger
because he sees the pain as threatening his security. A child at this stage of
development has a strong belief in magic, which can be used as a pain
management tool. Children often perceive pain as a punishment, so it is important
for the nurse to reassure the child that it is not his fault. It is not possible to reason
with a child at this stage of development, because he does not have the necessary
cognitive ability. Holding and comforting the child is a useful pain management
tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
D) The preschool-aged child does not have the vocabulary or logic skills to perceive
pain as a physiological response, so he will often respond with crying and anger
because he sees the pain as threatening his security. A child at this stage of
development has a strong belief in magic, which can be used as a pain
management tool. Children often perceive pain as a punishment, so it is important
for the nurse to reassure the child that it is not his fault. It is not possible to reason
with a child at this stage of development, because he does not have the necessary
cognitive ability. Holding and comforting the child is a useful pain management
tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
6
E) The preschool-aged child does not have the vocabulary or logic skills to perceive
pain as a physiological response, so he will often respond with crying and anger
because he sees the pain as threatening his security. A child at this stage of
development has a strong belief in magic, which can be used as a pain
management tool. Children often perceive pain as a punishment, so it is important
for the nurse to reassure the child that it is not his fault. It is not possible to reason
with a child at this stage of development, because he does not have the necessary
cognitive ability. Holding and comforting the child is a useful pain management
tool.
Cognitive Level: Analysis
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-3: Describe factors that affect the pain experience.
7) The nurse has a multicultural practice, seeing clients from a variety of ethnic backgrounds. The
nurse recognizes that people from what culture are most likely to believe that enduring pain is a
sign of strength?
7)
A) Mexican-Americans B) Puerto Ricans
C) Asian-Americans D) African-Americans
Answer: A
Explanation: A) Mexican-Americans might tend to view pain as a part of life and as an indicator of
the seriousness of an illness, believing that enduring pain is a sign of strength.
Puerto Ricans tend to be loud and outspoken in their expressions of pain as a
socially learned way to cope. The Chinese culture values silence, the Japanese
client might have a stoic response to pain, while the Filipino client might believe
pain is God’s will. African-American clients believe pain and suffering is part of
life, and is to be endured.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Assessment
B) Mexican-Americans might tend to view pain as a part of life and as an indicator of
the seriousness of an illness, believing that enduring pain is a sign of strength.
Puerto Ricans tend to be loud and outspoken in their expressions of pain as a
socially learned way to cope. The Chinese culture values silence, the Japanese
client might have a stoic response to pain, while the Filipino client might believe
pain is God’s will. African-American clients believe pain and suffering is part of
life, and is to be endured.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Assessment
C) Mexican-Americans might tend to view pain as a part of life and as an indicator of
the seriousness of an illness, believing that enduring pain is a sign of strength.
Puerto Ricans tend to be loud and outspoken in their expressions of pain as a
socially learned way to cope. The Chinese culture values silence, the Japanese
client might have a stoic response to pain, while the Filipino client might believe
pain is God’s will. African-American clients believe pain and suffering is part of
life, and is to be endured.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Assessment
7
D) Mexican-Americans might tend to view pain as a part of life and as an indicator of
the seriousness of an illness, believing that enduring pain is a sign of strength.
Puerto Ricans tend to be loud and outspoken in their expressions of pain as a
socially learned way to cope. The Chinese culture values silence, the Japanese
client might have a stoic response to pain, while the Filipino client might believe
pain is God’s will. African-American clients believe pain and suffering is part of
life, and is to be endured.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-3: Describe factors that affect the pain experience.
8) The nurse is caring for a client who had extensive surgery, and is now six days postoperative and
getting out of bed for the first time later this morning. When the nurse assesses the client for pain,
the client responds, “It hurts, but I don’t want to take any more drugs. I don’t want to end up
addicted.” Then nurse’s best response would be:
8)
A) “If you don’t take the pain medication on a regular schedule, you won’t get addicted.”
B) “People who have real pain are unlikely to become addicted to analgesics provided to treat
the pain.”
C) “You are wise to be concerned, and after six days it is probably time to stop taking narcotics if
you can manage the pain in other ways.”
D) “Don’t worry about getting addicted. I will make sure you don’t get addicted.”
Answer: B
Explanation: A) Many clients worry about becoming addicted to narcotic analgesics if they are
required for more than a few days. It is important for the nurse to reassure the
client by providing truthful information. Option 1 is not true. Option 3 agrees with
the client and is also untrue. Option 4 takes the control away from the client, where
it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Many clients worry about becoming addicted to narcotic analgesics if they are
required for more than a few days. It is important for the nurse to reassure the
client by providing truthful information. Option 1 is not true. Option 3 agrees with
the client and is also untrue. Option 4 takes the control away from the client, where
it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) Many clients worry about becoming addicted to narcotic analgesics if they are
required for more than a few days. It is important for the nurse to reassure the
client by providing truthful information. Option 1 is not true. Option 3 agrees with
the client and is also untrue. Option 4 takes the control away from the client, where
it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
8
D) Many clients worry about becoming addicted to narcotic analgesics if they are
required for more than a few days. It is important for the nurse to reassure the
client by providing truthful information. Option 1 is not true. Option 3 agrees with
the client and is also untrue. Option 4 takes the control away from the client, where
it belongs, and puts it in the hands of the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-4: List barriers to pain management.
9) The nurse working in a surgical center is caring for a client who had an abdominal nevus removed.
The client is complaining of intense pain. The nurse would:
9)
A) Administer a non-narcotic analgesic because the client had minor surgery.
B) Attempt to divert the client without administering an analgesic because the surgery was so
minor.
C) Administer the stronger analgesic ordered by the physician.
D) Notify the physician that the client’s pain is excessive for the minor surgery performed.
Answer: C
Explanation: A) Pain perception is what the client says it is, and the nurse should medicate the
client based on the client’s description of the pain, not what the nurse anticipates. If
the client reports severe pain, the nurse should administer strong analgesics.
Clients who have minor surgery can still experience severe pain, and
administering weaker analgesics when the client reports severe pain would not be
responsible practice. Diverting the client most likely will not be effective alone,
although diversion might be possible after administering the analgesic. There is no
need to notify the physician unless the nurse’s assessment indicates there is
something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Pain perception is what the client says it is, and the nurse should medicate the
client based on the client’s description of the pain, not what the nurse anticipates. If
the client reports severe pain, the nurse should administer strong analgesics.
Clients who have minor surgery can still experience severe pain, and
administering weaker analgesics when the client reports severe pain would not be
responsible practice. Diverting the client most likely will not be effective alone,
although diversion might be possible after administering the analgesic. There is no
need to notify the physician unless the nurse’s assessment indicates there is
something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
9
C) Pain perception is what the client says it is, and the nurse should medicate the
client based on the client’s description of the pain, not what the nurse anticipates. If
the client reports severe pain, the nurse should administer strong analgesics.
Clients who have minor surgery can still experience severe pain, and
administering weaker analgesics when the client reports severe pain would not be
responsible practice. Diverting the client most likely will not be effective alone,
although diversion might be possible after administering the analgesic. There is no
need to notify the physician unless the nurse’s assessment indicates there is
something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Pain perception is what the client says it is, and the nurse should medicate the
client based on the client’s description of the pain, not what the nurse anticipates. If
the client reports severe pain, the nurse should administer strong analgesics.
Clients who have minor surgery can still experience severe pain, and
administering weaker analgesics when the client reports severe pain would not be
responsible practice. Diverting the client most likely will not be effective alone,
although diversion might be possible after administering the analgesic. There is no
need to notify the physician unless the nurse’s assessment indicates there is
something unusual occurring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-4: List barriers to pain management.
10) The nurse is working on a surgical unit, and overhears another nurse say, “That client is asking for
pain medication again. He is constantly on the call bell, always reporting how severe his pain is,
and I think he’s just drug-seeking. I’m going to make him wait the full four hours before I give this
medication again.” The nurse:
10)
A) Ignores the situation because the client in question is not this nurse’s responsibility.
B) Enters the nurse’s station, reprimands the nurse, and completes an incident or variance report.
C) Pulls the second nurse aside and reminds him that the sensation of pain is subjective, and that
professionals have a duty to believe clients’ reports of their symptoms.
D) Informs the charge nurse of what was overheard.
Answer: C
Explanation: A) It is every nurse’s responsibility to speak up and advocate for the client when
situations arise that place the client at risk of incorrect treatment. However, the
nurse would address the situation privately, and not in front of others at the nurse’s
station. Informing the charge nurse would only be necessary if the nurse who was
overheard did not respond constructively to the nurse’s correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) It is every nurse’s responsibility to speak up and advocate for the client when
situations arise that place the client at risk of incorrect treatment. However, the
nurse would address the situation privately, and not in front of others at the nurse’s
station. Informing the charge nurse would only be necessary if the nurse who was
overheard did not respond constructively to the nurse’s correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
10
C) It is every nurse’s responsibility to speak up and advocate for the client when
situations arise that place the client at risk of incorrect treatment. However, the
nurse would address the situation privately, and not in front of others at the nurse’s
station. Informing the charge nurse would only be necessary if the nurse who was
overheard did not respond constructively to the nurse’s correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) It is every nurse’s responsibility to speak up and advocate for the client when
situations arise that place the client at risk of incorrect treatment. However, the
nurse would address the situation privately, and not in front of others at the nurse’s
station. Informing the charge nurse would only be necessary if the nurse who was
overheard did not respond constructively to the nurse’s correction.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 9-5: Identify key factors in pain management.
11) The nurse is working on the orthopedic unit, and is caring for a client who complains of back pain.
The nurse’s best response includes: (Select all that apply.)
11)
A) “I’m sorry you’re hurting. I want to make you feel better.”
B) “People with back pain experience very different symptoms. Tell me more about your back.”
C) “You had medication for your pain at 4 p.m., so I can’t give you any more until 8 p.m.,
because the doctor ordered it every four hours.”
D) “Does anything other than your back hurt?”
E) “Why don’t you try another position to make it feel better until it’s time for more pain
medication?”
Answer: A, B, D
Explanation: A) The nurse should inform the client that she will work to make the client feel better,
seek more information about the type of pain the client is experiencing, and
question any other discomforts the client may be experiencing. Allowing the client
to remain in pain would not be prudent practice, and would be lacking in caring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The nurse should inform the client that she will work to make the client feel better,
seek more information about the type of pain the client is experiencing, and
question any other discomforts the client may be experiencing. Allowing the client
to remain in pain would not be prudent practice, and would be lacking in caring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The nurse should inform the client that she will work to make the client feel better,
seek more information about the type of pain the client is experiencing, and
question any other discomforts the client may be experiencing. Allowing the client
to remain in pain would not be prudent practice, and would be lacking in caring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
11
D) The nurse should inform the client that she will work to make the client feel better,
seek more information about the type of pain the client is experiencing, and
question any other discomforts the client may be experiencing. Allowing the client
to remain in pain would not be prudent practice, and would be lacking in caring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
E) The nurse should inform the client that she will work to make the client feel better,
seek more information about the type of pain the client is experiencing, and
question any other discomforts the client may be experiencing. Allowing the client
to remain in pain would not be prudent practice, and would be lacking in caring.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-5: Identify key factors in pain management.
12) The hospice nurse is making a home visit to a client with terminal cancer. The client reports poor
pain control, and the client’s spouse says, “I’m giving such big doses of medication, I’m afraid I’m
going to overdose him if I give him more.” The nurse’s best response would be:
12)
A) “You’re wise to be concerned. These are very strong medications you’re administering.”
B) “You want him to be comfortable but you don’t want to endanger his life. Let’s talk about the
medication you’re giving and warning signs you’ll see if the dosage you’re administering is
too high.”
C) “I hear what you’re saying, but you’re not giving enough pain medication, so he is in severe
pain. You need to give more.”
D) “You aren’t giving adequate pain relief, and he is in severe pain as a result.”
Answer: B
Explanation: A) It is not unusual for a family caregiver to withhold medication out of fear of
overdosing the cancer client. It is important for the nurse to inform the caregiver
that his feelings are not unusual, and then provide him with the information he
needs to make an informed and appropriate decision that will make the client
more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel
guilty, and do not provide him with the information he needs to perform better.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) It is not unusual for a family caregiver to withhold medication out of fear of
overdosing the cancer client. It is important for the nurse to inform the caregiver
that his feelings are not unusual, and then provide him with the information he
needs to make an informed and appropriate decision that will make the client
more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel
guilty, and do not provide him with the information he needs to perform better.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
12
C) It is not unusual for a family caregiver to withhold medication out of fear of
overdosing the cancer client. It is important for the nurse to inform the caregiver
that his feelings are not unusual, and then provide him with the information he
needs to make an informed and appropriate decision that will make the client
more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel
guilty, and do not provide him with the information he needs to perform better.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) It is not unusual for a family caregiver to withhold medication out of fear of
overdosing the cancer client. It is important for the nurse to inform the caregiver
that his feelings are not unusual, and then provide him with the information he
needs to make an informed and appropriate decision that will make the client
more comfortable. Option 1 is untrue. Options 3 and 4 make the caregiver feel
guilty, and do not provide him with the information he needs to perform better.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-5: Identify key factors in pain management.
13) The nurse enters the postoperative client’s room and finds the client perspiring with fists clenched.
As the nurse administers routine medications and provides care, the client is pleasant and
cooperative. The nurse:
13)
A) Documents “no complaints of pain offered” and assesses that the client is comfortable.
B) Asks the client if he is in pain.
C) Informs the client he looks uncomfortable and asks him to describe his pain.
D) Instructs the client to use the call bell if he experiences pain.
Answer: C
Explanation: A) It is the nurse’s responsibility to assess for pain and not wait for the client to
mention it. Some clients might feel that admitting to pain is a sign of weakness,
and might not bring it up unless the nurse specifically refers to the client’s
apparent discomfort and asks them to describe their pain and indicates the client’s
apparent discomfort. The client’s body language indicates the likelihood of pain, so
option 1 is not correct. Option 4 puts the responsibility for pain assessment on the
client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) It is the nurse’s responsibility to assess for pain and not wait for the client to
mention it. Some clients might feel that admitting to pain is a sign of weakness,
and might not bring it up unless the nurse specifically refers to the client’s
apparent discomfort and asks them to describe their pain and indicates the client’s
apparent discomfort. The client’s body language indicates the likelihood of pain, so
option 1 is not correct. Option 4 puts the responsibility for pain assessment on the
client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
13
C) It is the nurse’s responsibility to assess for pain and not wait for the client to
mention it. Some clients might feel that admitting to pain is a sign of weakness,
and might not bring it up unless the nurse specifically refers to the client’s
apparent discomfort and asks them to describe their pain and indicates the client’s
apparent discomfort. The client’s body language indicates the likelihood of pain, so
option 1 is not correct. Option 4 puts the responsibility for pain assessment on the
client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) It is the nurse’s responsibility to assess for pain and not wait for the client to
mention it. Some clients might feel that admitting to pain is a sign of weakness,
and might not bring it up unless the nurse specifically refers to the client’s
apparent discomfort and asks them to describe their pain and indicates the client’s
apparent discomfort. The client’s body language indicates the likelihood of pain, so
option 1 is not correct. Option 4 puts the responsibility for pain assessment on the
client instead of on the nurse.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-6: Describe the two major components of pain assessment.
14) When assessing the client’s pain, the nurse uses the mnemonic COLDERR, with the C representing: 14)
A) Color. B) Cardiac. C) Comfort. D) Character.
Answer: D
Explanation: A) The C in the COLDERR mnemonic stands for character, meaning a description of
what the pain feels like, such as sharp, stabbing, dull, or aching.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
B) The C in the COLDERR mnemonic stands for character, meaning a description of
what the pain feels like, such as sharp, stabbing, dull, or aching.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
C) The C in the COLDERR mnemonic stands for character, meaning a description of
what the pain feels like, such as sharp, stabbing, dull, or aching.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
D) The C in the COLDERR mnemonic stands for character, meaning a description of
what the pain feels like, such as sharp, stabbing, dull, or aching.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-6: Describe the two major components of pain assessment.
14
15) The nurse is obtaining a pain history. The client reports pain in his right ear. The nurse’s best
response would be:
15)
A) “Is the pain minor?”
B) “Do you have anything else that hurts?”
C) “Tell me more about the pain and what you do for it when it hurts.”
D) “I’ll note that in the record. Is there anything else I should know?”
Answer: C
Explanation: A) When the client reports pain, the nurse should seek more information. The
COLDERR mnemonic is effective in helping the nurse to assess all aspects of the
pain, including character, onset, location, duration, exacerbation, relief, and
radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
B) When the client reports pain, the nurse should seek more information. The
COLDERR mnemonic is effective in helping the nurse to assess all aspects of the
pain, including character, onset, location, duration, exacerbation, relief, and
radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
C) When the client reports pain, the nurse should seek more information. The
COLDERR mnemonic is effective in helping the nurse to assess all aspects of the
pain, including character, onset, location, duration, exacerbation, relief, and
radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
D) When the client reports pain, the nurse should seek more information. The
COLDERR mnemonic is effective in helping the nurse to assess all aspects of the
pain, including character, onset, location, duration, exacerbation, relief, and
radiation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-7: Identify data to collect and analyze when obtaining a comprehensive pain
history.
15
16) When conducting a pain history, the nurse should obtain data regarding all of the following except: 16)
A) Intensity, quality, and patterns.
B) Precipitating factors, alleviating factors, and associated symptoms.
C) Effects on activities of daily living, coping resources, and affective responses.
D) Significant other’s assessment of the pain.
Answer: D
Explanation: A) During a pain history, it is the client’s description of the pain that is most
important, not the significant other’s. The nurse should determine all of the other
factors in order to put a plan of care in place that will help the client address and
treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
B) During a pain history, it is the client’s description of the pain that is most
important, not the significant other’s. The nurse should determine all of the other
factors in order to put a plan of care in place that will help the client address and
treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
C) During a pain history, it is the client’s description of the pain that is most
important, not the significant other’s. The nurse should determine all of the other
factors in order to put a plan of care in place that will help the client address and
treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
D) During a pain history, it is the client’s description of the pain that is most
important, not the significant other’s. The nurse should determine all of the other
factors in order to put a plan of care in place that will help the client address and
treat the pain effectively.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-7: Identify data to collect and analyze when obtaining a comprehensive pain
history.
17) When caring for an elderly client who does not speak English, the nurse can best assess pain using: 17)
A) The FACES rating scale. B) An interpreter.
C) The client’s affect. D) The client’s vital signs.
Answer: A
Explanation: A) An interpreter might not always be readily available, so the FACES rating scale can
be used because it is not necessary to use language. If an interpreter is available,
she can be utilized to discuss the pain in more detail, but the FACES rating scale
will help the nurse to respond to the client’s pain appropriately and quickly
without waiting for an interpreter. Affect and vital signs might not be accurate
indicators of the client’s discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
16
B) An interpreter might not always be readily available, so the FACES rating scale can
be used because it is not necessary to use language. If an interpreter is available,
she can be utilized to discuss the pain in more detail, but the FACES rating scale
will help the nurse to respond to the client’s pain appropriately and quickly
without waiting for an interpreter. Affect and vital signs might not be accurate
indicators of the client’s discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
C) An interpreter might not always be readily available, so the FACES rating scale can
be used because it is not necessary to use language. If an interpreter is available,
she can be utilized to discuss the pain in more detail, but the FACES rating scale
will help the nurse to respond to the client’s pain appropriately and quickly
without waiting for an interpreter. Affect and vital signs might not be accurate
indicators of the client’s discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
D) An interpreter might not always be readily available, so the FACES rating scale can
be used because it is not necessary to use language. If an interpreter is available,
she can be utilized to discuss the pain in more detail, but the FACES rating scale
will help the nurse to respond to the client’s pain appropriately and quickly
without waiting for an interpreter. Affect and vital signs might not be accurate
indicators of the client’s discomfort.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-7: Identify data to collect and analyze when obtaining a comprehensive pain
history.
17
18) The nurse uses combinations of drugs to reduce the need for high doses of any one medication and
to maximize pain control with a minimum of side effects or toxicity, which is called:
18)
A) Polypharmacy. B) Rational polypharmacy.
C) Analgesia. D) Dose-reduction pharmacology.
Answer: B
Explanation: A) This description defines rational polypharmacy, which is a multidrug strategy
combined with nonpharmacological approaches to manage the client’s pain.
Polypharmacy is a generic term for multiple medication administration, often used
with elders who are on many medications. Analgesia is a classification of
medication used for pain control. Dose-reduction pharmacology is not a real term.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
B) This description defines rational polypharmacy, which is a multidrug strategy
combined with nonpharmacological approaches to manage the client’s pain.
Polypharmacy is a generic term for multiple medication administration, often used
with elders who are on many medications. Analgesia is a classification of
medication used for pain control. Dose-reduction pharmacology is not a real term.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
C) This description defines rational polypharmacy, which is a multidrug strategy
combined with nonpharmacological approaches to manage the client’s pain.
Polypharmacy is a generic term for multiple medication administration, often used
with elders who are on many medications. Analgesia is a classification of
medication used for pain control. Dose-reduction pharmacology is not a real term.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
D) This description defines rational polypharmacy, which is a multidrug strategy
combined with nonpharmacological approaches to manage the client’s pain.
Polypharmacy is a generic term for multiple medication administration, often used
with elders who are on many medications. Analgesia is a classification of
medication used for pain control. Dose-reduction pharmacology is not a real term.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of
medications and routes for opioid delivery.
19) According to the World Health Organization Three-Step Approach, if the nurse is caring for a
client complaining of mild pain that persists after using full doses of step 1 medications, the nurse
would administer: (Select all that apply.)
19)
A) Codeine
B) Fentanyl.
C) Oxycodone with acetaminophen.
D) Hydrocodone with ibuprofen.
E) Morphine.
Answer: A, C, D
18
Explanation: A) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain
persists or the pain is moderate, the second step is a weak opioids, or a
combination of opioid and non-opioid medicine can be used. If moderate pain
persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain
persists or the pain is moderate, the second step is a weak opioids, or a
combination of opioid and non-opioid medicine can be used. If moderate pain
persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
C) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain
persists or the pain is moderate, the second step is a weak opioids, or a
combination of opioid and non-opioid medicine can be used. If moderate pain
persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain
persists or the pain is moderate, the second step is a weak opioids, or a
combination of opioid and non-opioid medicine can be used. If moderate pain
persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
E) For mild pain, a non-opioid analgesic is the appropriate starting point. If the pain
persists or the pain is moderate, the second step is a weak opioids, or a
combination of opioid and non-opioid medicine can be used. If moderate pain
persists or the pain is severe, stronger opiates are provided.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of
medications and routes for opioid delivery.
20) The nurse administers a nonsteroidal antiinflammatory drug (NSAID) knowing that the effects of
this medication include: (Select all that apply.)
20)
A) Anti-inflammatory effects.
B) Analgesic effects.
C) Antipyretic effects.
D) Sedating effects.
E) Anesthetic effects.
Answer: A, B, C
Explanation: A) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report
being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
19
B) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report
being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
C) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report
being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
D) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report
being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
E) Ibuprofen is an anti-inflammatory, analgesic, and antipyretic. It does not have
sedating or anesthetic effects in most clients, although some clients might report
being able to fall asleep more easily once pain is reduced.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of
medications and routes for opioid delivery.
20
21) The nurse would administer acetaminophen instead of ibuprofen if which of the following effects
were not desired?
21)
A) Anti-inflammatory effects
B) Analgesic effects
C) Antipyretic effects
D) Antipyretic and anti-inflammatory effects
Answer: A
Explanation: A) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects.
However, both acetaminophen and ibuprofen have analgesic and antipyretic
effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
B) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects.
However, both acetaminophen and ibuprofen have analgesic and antipyretic
effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
C) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects.
However, both acetaminophen and ibuprofen have analgesic and antipyretic
effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
D) Acetaminophen, unlike ibuprofen, does not have anti-inflammatory effects.
However, both acetaminophen and ibuprofen have analgesic and antipyretic
effects.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of
medications and routes for opioid delivery.
21
22) After administering an opioid analgesic, the nurse assesses the client using the sedation scale and
finds the client sleeping and arousable, but the client drifts off to sleep during conversation. The
nurse would rate the client’s level of sedation as:
22)
A) 1. B) 2. C) 3. D) 4.
Answer: C
Explanation: A) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation.
Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is
somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
B) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation.
Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is
somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
C) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation.
Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is
somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
D) Level 3 is frequently drowsy, arousable, drifts off to sleep during conversation.
Level 1 is awake and alert, 2 is slightly drowsy but arousable, and level 4 is
somnolent, minimal-to-no response to physical stimulation.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-8: Describe pharmacologic pain management, including classifications of
medications and routes for opioid delivery.
22
23) The client reports difficulty sleeping related to anxiety. Which of the following nonpharmacologic
pain management interventions might the nurse consider performing in order to relax the client?
23)
A) Acupuncture B) Acupressure C) Massage D) Distraction
Answer: C
Explanation: A) Massage is used for relaxation, and can be effective in helping the client who is
anxious. Distraction, acupressure, and acupuncture are not used for relaxation,
although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
B) Massage is used for relaxation, and can be effective in helping the client who is
anxious. Distraction, acupressure, and acupuncture are not used for relaxation,
although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
C) Massage is used for relaxation, and can be effective in helping the client who is
anxious. Distraction, acupressure, and acupuncture are not used for relaxation,
although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
D) Massage is used for relaxation, and can be effective in helping the client who is
anxious. Distraction, acupressure, and acupuncture are not used for relaxation,
although they can be effective in helping the client cope with pain.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 9-9: Describe nonpharmacologic pain management interventions.
23
24) The nurse has administered an oral analgesic to a client complaining of a mild-to-moderate
headache. Which of the following distractions would the nurse consider to help relieve the client’s
discomfort until the analgesic takes effect?
24)
A) Reading or watching TV B) Video or computer games
C) Slow rhythmic breathing D) Crossword puzzles
Answer: C
Explanation: A) Slow rhythmic breathing would be an effective distraction technique for a client
with a headache. Reading, watching TV, video games, and crossword puzzles
might exacerbate the symptoms because the client with a headache is often more
comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Planning
B) Slow rhythmic breathing would be an effective distraction technique for a client
with a headache. Reading, watching TV, video games, and crossword puzzles
might exacerbate the symptoms because the client with a headache is often more
comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Planning
C) Slow rhythmic breathing would be an effective distraction technique for a client
with a headache. Reading, watching TV, video games, and crossword puzzles
might exacerbate the symptoms because the client with a headache is often more
comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Planning
D) Slow rhythmic breathing would be an effective distraction technique for a client
with a headache. Reading, watching TV, video games, and crossword puzzles
might exacerbate the symptoms because the client with a headache is often more
comfortable in a dark, low-stimuli environment.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Planning
Objective: Learning Outcome 9-9: Describe nonpharmacologic pain management interventions.
24
25) Which of the following can the nurse safely delegate to the unlicensed assistive personnel (UAP)? 25)
A) Initial assessment of pain
B) Regular reassessment of pain
C) Providing a massage and repositioning the client in pain
D) Administration of an oral analgesic
Answer: C
Explanation: A) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot
administer oral analgesics. The UAP can safely provide a massage and reposition
the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
B) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot
administer oral analgesics. The UAP can safely provide a massage and reposition
the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
C) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot
administer oral analgesics. The UAP can safely provide a massage and reposition
the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
D) Assessment is never delegated to the client, (options 1 and 2), and UAPs cannot
administer oral analgesics. The UAP can safely provide a massage and reposition
the client.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
Objective: Learning Outcome 9-10: Recognize when it is appropriate to delegate pain management skills to
unlicensed assistive personnel.
26) The unlicensed assistive personnel (UAP) informs the nurse that the client is complaining of severe
postoperative pain and requests pain medication. Which of the following actions would be
appropriate for the nurse to perform?
26)
A) Give the client an analgesic.
B) Assess the client’s pain and respond as indicated.
C) Ask the UAP for more data regarding the client’s pain.
D) Tell the UAP to inform the client that the nurse will be in as soon as possible.
Answer: B
Explanation: A) When the UAP reports a problem, the nurse should assess the client thoroughly
before acting. Giving the client an analgesic without a thorough assessment by the
nurse would be dangerous. Asking the UAP for more information is not efficient
because the nurse should talk directly to the client. Delaying response to the client’s
needs would not be effective nursing practice.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
25
B) When the UAP reports a problem, the nurse should assess the client thoroughly
before acting. Giving the client an analgesic without a thorough assessment by the
nurse would be dangerous. Asking the UAP for more information is not efficient
because the nurse should talk directly to the client. Delaying response to the client’s
needs would not be effective nursing practice.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) When the UAP reports a problem, the nurse should assess the client thoroughly
before acting. Giving the client an analgesic without a thorough assessment by the
nurse would be dangerous. Asking the UAP for more information is not efficient
because the nurse should talk directly to the client. Delaying response to the client’s
needs would not be effective nursing practice.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) When the UAP reports a problem, the nurse should assess the client thoroughly
before acting. Giving the client an analgesic without a thorough assessment by the
nurse would be dangerous. Asking the UAP for more information is not efficient
because the nurse should talk directly to the client. Delaying response to the client’s
needs would not be effective nursing practice.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-10: Recognize when it is appropriate to delegate pain management skills to
unlicensed assistive personnel.
27) The nurse is assessing the client’s chronic pain. The client indicates the pain is in the upper right
quadrant of the abdomen, rates the pain as a 9 on a 1-10 scale, and describes the pain as sharp and
continuous. What else would the nurse assess regarding this client’s pain?
27)
A) Onset, duration, and recurrence B) Location
C) Intensity D) Quality
Answer: A
Explanation: A) The nurse would question when the pain began, how long it has lasted, and what
causes the pain to recur, if it is intermittent. The client has already indicated the
location (upper right quadrant), intensity (9 on a 1-10 scale), and quality (sharp
and continuous).
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
B) The nurse would question when the pain began, how long it has lasted, and what
causes the pain to recur, if it is intermittent. The client has already indicated the
location (upper right quadrant), intensity (9 on a 1-10 scale), and quality (sharp
and continuous).
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
26
C) The nurse would question when the pain began, how long it has lasted, and what
causes the pain to recur, if it is intermittent. The client has already indicated the
location (upper right quadrant), intensity (9 on a 1-10 scale), and quality (sharp
and continuous).
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
D) The nurse would question when the pain began, how long it has lasted, and what
causes the pain to recur, if it is intermittent. The client has already indicated the
location (upper right quadrant), intensity (9 on a 1-10 scale), and quality (sharp
and continuous).
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Assessment
Objective: Learning Outcome 9-11: Verbalize the steps used when:
A. Assessing the client in pain.
B. Managing pain with a patient-controlled analgesia pump.
C. Managing a transcutaneous electrical nerve stimulation unit.
D. Providing a back massage.
E. Teaching progressive muscle relaxation.
F. Assisting with guided imagery.
28) The nurse is initiating a patient-controlled anesthesia (PCA) pump delivering morphine sulfate for
a 9-year-old girl post-appendectomy. Prior to connecting the PCA tubing to the client’s IV fluid
line, the nurse’s priority action would be to:
28)
A) Clamp the PCA tubing.
B) Deliver the loading dose.
C) Set the safety parameters for the infusion on the PCA pump.
D) Clamp the client’s primary IV fluid line.
Answer: A
Explanation: A) Before connecting the PCA to the client’s IV line, the nurse should make sure the
PCA tubing is clamped to avoid an accidental administration of narcotics. The
loading dose is administered after properly programming the PCA pump. After
connecting the PCA tubing to the client’s IV line, the nurse would set the safety
parameters. Clamping the client’s primary IV line could result in occlusion of the
IV catheter.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Before connecting the PCA to the client’s IV line, the nurse should make sure the
PCA tubing is clamped to avoid an accidental administration of narcotics. The
loading dose is administered after properly programming the PCA pump. After
connecting the PCA tubing to the client’s IV line, the nurse would set the safety
parameters. Clamping the client’s primary IV line could result in occlusion of the
IV catheter.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
27
C) Before connecting the PCA to the client’s IV line, the nurse should make sure the
PCA tubing is clamped to avoid an accidental administration of narcotics. The
loading dose is administered after properly programming the PCA pump. After
connecting the PCA tubing to the client’s IV line, the nurse would set the safety
parameters. Clamping the client’s primary IV line could result in occlusion of the
IV catheter.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Before connecting the PCA to the client’s IV line, the nurse should make sure the
PCA tubing is clamped to avoid an accidental administration of narcotics. The
loading dose is administered after properly programming the PCA pump. After
connecting the PCA tubing to the client’s IV line, the nurse would set the safety
parameters. Clamping the client’s primary IV line could result in occlusion of the
IV catheter.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-11: Verbalize the steps used when:
A. Assessing the client in pain.
B. Managing pain with a patient-controlled analgesia pump.
C. Managing a transcutaneous electrical nerve stimulation unit.
D. Providing a back massage.
E. Teaching progressive muscle relaxation.
F. Assisting with guided imagery.
29) The nurse is applying a TENS unit to a client in pain. Prior to applying the electrodes, the nurse: 29)
A) Turns the unit on.
B) Washes, rinses, and dries the designated area with soap and water.
C) Increases the amplitude to the desired setting.
D) Changes the battery.
Answer: B
Explanation: A) Washing, rinsing, and drying the area will help to improve the contact of the
electrodes to the skin. The unit should not be turned on until the electrodes are in
place, to avoid injuring the client. The amplitude is slowly increased once the
electrodes are in place to determine the level that is most effective for the client. The
battery is changed when the unit is removed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) Washing, rinsing, and drying the area will help to improve the contact of the
electrodes to the skin. The unit should not be turned on until the electrodes are in
place, to avoid injuring the client. The amplitude is slowly increased once the
electrodes are in place to determine the level that is most effective for the client. The
battery is changed when the unit is removed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
28
C) Washing, rinsing, and drying the area will help to improve the contact of the
electrodes to the skin. The unit should not be turned on until the electrodes are in
place, to avoid injuring the client. The amplitude is slowly increased once the
electrodes are in place to determine the level that is most effective for the client. The
battery is changed when the unit is removed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) Washing, rinsing, and drying the area will help to improve the contact of the
electrodes to the skin. The unit should not be turned on until the electrodes are in
place, to avoid injuring the client. The amplitude is slowly increased once the
electrodes are in place to determine the level that is most effective for the client. The
battery is changed when the unit is removed.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 9-11: Verbalize the steps used when:
A. Assessing the client in pain.
B. Managing pain with a patient-controlled analgesia pump.
C. Managing a transcutaneous electrical nerve stimulation unit.
D. Providing a back massage.
E. Teaching progressive muscle relaxation.
F. Assisting with guided imagery.
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
30) The nurse is administering a back massage to the client. Place the following steps in the
proper order of performance.
1. Massage the areas over the right and left iliac crests.
2. Move your hands up the center of the back.
3. Massage the sacral area using smooth, circular strokes.
4. Massage both scapulae.
5. Move your hands down the side of the back.
30)
Answer: 3, 2, 4, 5, 1
Explanation: When administering a back massage, the nurse begins over the sacral area,
using smooth, circular strokes, and then slides the hands up the center of the
back, massaging over both scapulae. Slide the hands down the side of the back
to massage over both iliac crests.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-11: Verbalize the steps used when:
A. Assessing the client in pain.
B. Managing pain with a patient-controlled analgesia pump.
C. Managing a transcutaneous electrical nerve stimulation unit.
D. Providing a back massage.
E. Teaching progressive muscle relaxation.
F. Assisting with guided imagery.
29
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
31) The nurse is teaching progressive muscle relaxation techniques to the client, and explains the
rationale for the procedure is:
31)
A) A form of diversion that keeps your mind off of your stress.
B) By releasing muscle tension, the negative effects of stress can be lessened.
C) By relaxing the muscles, the pain the client is experiencing will cease.
D) It is a good form of exercise that will help you get into better shape so you won’t experience
any more pain.
Answer: B
Explanation: A) The rationale for progressive muscle relaxation is to release muscle tension and
minimize the negative effects of stress. It is not just a form of diversion, and will not
completely eliminate pain, although it might reduce the pain experience.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The rationale for progressive muscle relaxation is to release muscle tension and
minimize the negative effects of stress. It is not just a form of diversion, and will not
completely eliminate pain, although it might reduce the pain experience.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The rationale for progressive muscle relaxation is to release muscle tension and
minimize the negative effects of stress. It is not just a form of diversion, and will not
completely eliminate pain, although it might reduce the pain experience.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The rationale for progressive muscle relaxation is to release muscle tension and
minimize the negative effects of stress. It is not just a form of diversion, and will not
completely eliminate pain, although it might reduce the pain experience.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-11: Verbalize the steps used when:
A. Assessing the client in pain.
B. Managing pain with a patient-controlled analgesia pump.
C. Managing a transcutaneous electrical nerve stimulation unit.
D. Providing a back massage.
E. Teaching progressive muscle relaxation.
F. Assisting with guided imagery.
32) The nurse is assisting the client to initiate guided imagery. The nurse begins by: 32)
A) Asking the client to take slow, full diaphragmatic/abdominal breaths.
B) Asking the client to use progressive muscle relaxation exercises.
C) Guiding the client toward a most beautiful or peaceful place.
D) Suggesting a place where the client will find peace.
Answer: A
30
Explanation: A) The nurse begins by helping the client to relax using slow breaths. After deep
breathing, the client may be asked to use progressive muscle relaxation exercises,
and then the nurse will guide the client toward a peaceful place. The nurse should
never suggest a peaceful place, but should allow the client to choose the place
where he finds peace.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) The nurse begins by helping the client to relax using slow breaths. After deep
breathing, the client may be asked to use progressive muscle relaxation exercises,
and then the nurse will guide the client toward a peaceful place. The nurse should
never suggest a peaceful place, but should allow the client to choose the place
where he finds peace.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
C) The nurse begins by helping the client to relax using slow breaths. After deep
breathing, the client may be asked to use progressive muscle relaxation exercises,
and then the nurse will guide the client toward a peaceful place. The nurse should
never suggest a peaceful place, but should allow the client to choose the place
where he finds peace.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) The nurse begins by helping the client to relax using slow breaths. After deep
breathing, the client may be asked to use progressive muscle relaxation exercises,
and then the nurse will guide the client toward a peaceful place. The nurse should
never suggest a peaceful place, but should allow the client to choose the place
where he finds peace.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-11: Verbalize the steps used when:
A. Assessing the client in pain.
B. Managing pain with a patient-controlled analgesia pump.
C. Managing a transcutaneous electrical nerve stimulation unit.
D. Providing a back massage.
E. Teaching progressive muscle relaxation.
F. Assisting with guided imagery.
33) The postoperative client has been noting a steady decline in the amount of pain experienced over
the past week. Today, when she awakens, the pain is far more severe even at rest, and she informs
the nurse. What would be a priority intervention for the nurse to perform?
33)
A) Assess the client fully and notify the physician.
B) Explain to the client that it is not unusual to have a recurrence of severe pain in the
rehabilitative phase of recovery.
C) Administer stronger opioid analgesics and document in the client’s record.
D) Explain that the extra activity the client has been performing is the cause of the increased
discomfort.
Answer: A
31
Explanation: A) A sudden increase in pain can indicate infection or other complications, so the
nurse’s priority intervention is to assess the client fully and notify the physician
prior to administering an analgesic, in case the description of the pain is required
for the physician to determine cause. Option 2 is incorrect because it is unusual.
Option 3 would be incomplete, and could miss the significance of a very important
symptom. Option 4 is incorrect, and also ignores the importance of the symptoms
reported by the client.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
B) A sudden increase in pain can indicate infection or other complications, so the
nurse’s priority intervention is to assess the client fully and notify the physician
prior to administering an analgesic, in case the description of the pain is required
for the physician to determine cause. Option 2 is incorrect because it is unusual.
Option 3 would be incomplete, and could miss the significance of a very important
symptom. Option 4 is incorrect, and also ignores the importance of the symptoms
reported by the client.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
C) A sudden increase in pain can indicate infection or other complications, so the
nurse’s priority intervention is to assess the client fully and notify the physician
prior to administering an analgesic, in case the description of the pain is required
for the physician to determine cause. Option 2 is incorrect because it is unusual.
Option 3 would be incomplete, and could miss the significance of a very important
symptom. Option 4 is incorrect, and also ignores the importance of the symptoms
reported by the client.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
D) A sudden increase in pain can indicate infection or other complications, so the
nurse’s priority intervention is to assess the client fully and notify the physician
prior to administering an analgesic, in case the description of the pain is required
for the physician to determine cause. Option 2 is incorrect because it is unusual.
Option 3 would be incomplete, and could miss the significance of a very important
symptom. Option 4 is incorrect, and also ignores the importance of the symptoms
reported by the client.
Cognitive Level: Analysis
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 9-12: Demonstrate appropriate documentation and reporting of pain
assessment and interventions.
34) The nurse documents the assessment and interventions performed to relieve the client’s pain on a
pain management flow sheet in order to: (Select all that apply.)
34)
A) Reduce time spent on documentation.
B) Clarify and communicate each client’s pain experience.
C) More accurately document the pain management efforts performed by the nurse.
D) Enhance pain relief efforts.
E) Ensure continuity of care
Answer: B, D, E
32
Explanation: A) The pain management flow sheet helps to clarify and communicate each client’s
pain experience to other members of the health care team, enhances pain
management effectiveness, and ensures that other care providers will recognize
what has worked for pain relief in the past, ensuring continuity of care. It is not
used to reduce time spent on documentation, although this can be a pleasant side
effect. Pain management should be accurately documented no matter what form is
used.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) The pain management flow sheet helps to clarify and communicate each client’s
pain experience to other members of the health care team, enhances pain
management effectiveness, and ensures that other care providers will recognize
what has worked for pain relief in the past, ensuring continuity of care. It is not
used to reduce time spent on documentation, although this can be a pleasant side
effect. Pain management should be accurately documented no matter what form is
used.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) The pain management flow sheet helps to clarify and communicate each client’s
pain experience to other members of the health care team, enhances pain
management effectiveness, and ensures that other care providers will recognize
what has worked for pain relief in the past, ensuring continuity of care. It is not
used to reduce time spent on documentation, although this can be a pleasant side
effect. Pain management should be accurately documented no matter what form is
used.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) The pain management flow sheet helps to clarify and communicate each client’s
pain experience to other members of the health care team, enhances pain
management effectiveness, and ensures that other care providers will recognize
what has worked for pain relief in the past, ensuring continuity of care. It is not
used to reduce time spent on documentation, although this can be a pleasant side
effect. Pain management should be accurately documented no matter what form is
used.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
E) The pain management flow sheet helps to clarify and communicate each client’s
pain experience to other members of the health care team, enhances pain
management effectiveness, and ensures that other care providers will recognize
what has worked for pain relief in the past, ensuring continuity of care. It is not
used to reduce time spent on documentation, although this can be a pleasant side
effect. Pain management should be accurately documented no matter what form is
used.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 9-12: Demonstrate appropriate documentation and reporting of pain
assessment and interventions.
33