1. A nurse is assessing a client’s pain. Which of the following is the most reliable indicator of the existence and intensity of pain?
A. Vital signs
B. The client’s self-report
C. The presence of grimacing
D. Physician’s assessment
Answer: B - The client’s self-report
Rationale: The ...
1. A nurse is assessing a client’s pain. Which of the following is the most reliable
indicator of the existence and intensity of pain?
A. Vital signs
B. The client’s self-report
C. The presence of grimacing
D. Physician’s assessment
Answer: B - The client’s self-report
Rationale: The client’s self-report is the most reliable indicator of pain. Pain is subjective, and
only the client can accurately describe the pain they are experiencing.
2. A nurse is caring for a postoperative client. Which action should the nurse
perform first when the client reports pain?
A. Administer the prescribed analgesic
B. Assess the client’s pain level using a standardized scale
C. Offer the client a non-pharmacological method of pain relief
D. Notify the healthcare provider
Answer: B - Assess the client’s pain level using a standardized scale
Rationale: Assessment is always the first step in the nursing process. The nurse should assess
the pain level using a standardized pain scale to determine the appropriate intervention.
3. The nurse is caring for a client who received an epidural for pain
management. Which of the following findings should the nurse report
immediately?
A. Nausea
B. Pruritus
C. Difficulty breathing
D. Hypotension
Answer: C - Difficulty breathing
Rationale: Difficulty breathing may indicate respiratory depression, a serious side effect of
opioid analgesia, especially with epidural administration. This requires immediate intervention.
,4. Which pain scale is most appropriate for use with a non-verbal adult client
with cognitive impairment?
A. Visual Analog Scale (VAS)
B. Numerical Rating Scale (NRS)
C. Wong-Baker FACES Pain Rating Scale
D. FLACC (Face, Legs, Activity, Cry, Consolability) scale
Answer: D - FLACC (Face, Legs, Activity, Cry, Consolability) scale
Rationale: The FLACC scale is often used to assess pain in non-verbal clients, such as those
with cognitive impairment, by observing behaviors and physiological indicators.
5. A nurse is preparing to administer an opioid analgesic to a client with severe
pain. Which assessment finding is a contraindication for opioid administration?
A. Respiratory rate of 10 breaths per minute
B. Blood pressure of 140/90 mmHg
C. Heart rate of 100 beats per minute
D. Client reports nausea
Answer: A - Respiratory rate of 10 breaths per minute
Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression. Opioids
can further depress the respiratory system, so the medication should be withheld and the
healthcare provider notified.
6. A client reports chronic pain from arthritis. Which statement by the nurse
demonstrates understanding of chronic pain management?
A. "You should take your pain medication only when the pain is severe."
B. "It’s important to take your pain medication around the clock to manage your pain
effectively."
C. "Exercise will increase your pain, so you should avoid it."
D. "You should limit the use of non-pharmacological methods of pain relief."
Answer: B - "It’s important to take your pain medication around the clock to manage your
pain effectively."
Rationale: Chronic pain is best managed by administering analgesics on a regular schedule
(around the clock) to maintain consistent pain relief.
, 7. A client receiving morphine for postoperative pain complains of constipation.
Which nursing intervention is most appropriate to address this side effect?
A. Discontinue the morphine
B. Administer a stool softener as prescribed
C. Instruct the client to increase fluid intake to 500 mL/day
D. Limit the client’s intake of fiber-rich foods
Answer: B - Administer a stool softener as prescribed
Rationale: Constipation is a common side effect of opioid use. Administering a stool softener or
laxative as prescribed can help alleviate this side effect.
8. A client is receiving patient-controlled analgesia (PCA) for pain control.
Which statement by the client indicates a need for further teaching?
A. "I will push the button whenever I start to feel pain."
B. "I will push the button at least every hour, even if I don’t have pain."
C. "The machine is programmed to prevent an overdose."
D. "Only I should push the button to administer the medication."
Answer: B - "I will push the button at least every hour, even if I don’t have pain."
Rationale: PCA should be used by the client only when pain occurs, not on a scheduled basis or
when not in pain. This statement reflects a misunderstanding of the PCA system.
9. A nurse is educating a client about the use of non-pharmacological pain relief
methods. Which of the following statements indicates that the client understands
the teaching?
A. "Non-pharmacological methods will completely eliminate my pain."
B. "I can use relaxation techniques to help decrease my pain."
C. "I don’t need to use medications if I use non-pharmacological methods."
D. "Distraction will be ineffective for pain relief."
Answer: B - "I can use relaxation techniques to help decrease my pain."
Rationale: Relaxation techniques, such as deep breathing, can complement pharmacological
pain management and help reduce pain perception.
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