Pain Management (31 Questions)

1. You are caring for Mr. Thomas Leclerc, a 62-year-old patient recovering from abdominal surgery complicated by long-standing type 2 diabetes mellitus and peripheral neuropathy. Despite receiving hydromorphone (Dilaudid) IV every 4 hours for the past 24 hours, he continues to complain of burning, tingling pain in his lower legs and feet, rated 8/10, especially at night.

Upon assessment, you note that the pain has a shooting, electric quality, consistent with neuropathic pain, which does not respond well to opioids alone.
You review the current post-op medication orders, which include:
*Hydromorphone (Dilaudid) 1 mg IV q4h PRN
*Acetaminophen (Tylenol) 650 mg PO q6h scheduled

Question:
Which additional medication (s) would you expect the doctor will prescribe to better manage his pain? Choose TWO (2) answers. *
2.1 Mr. Robert Harris, a 72-year-old male, is admitted for an exploratory laparotomy under general anesthesia. His medical history includes:
-Hypertension (well-controlled with medication)
-Stable type 2 diabetes mellitus
-Chronic kidney failure
-Obstructive sleep apnea (OSA)

Following surgery, you are preparing his Therapeutic Nursing Plan (TNP).

Question:
What is the priority problem to address in Mr. Harris’s Therapeutic Nursing Plan (TNP)? *
2.2 One hour post-op, the nurse finds Mr. Harris:
-Unresponsive to verbal stimuli, arousable only to painful stimulation
-Respiratory rate: 8 breaths/minute
-Shallow breathing
-Pulse oximeter: 88% on 2L nasal cannula
-Skin: Cool and slightly pale
-No airway obstruction visible
-Snoring has stopped, but breathing is minimal

You review the postoperative medical orders, which include:
-Hydromorphone (Dilaudid) 1 mg IV q4h PRN for pain
-Naloxone (Narcan) 0.1 mg IV PRN for signs of respiratory depression
-Oxygen 2–4 L/min via nasal cannula PRN
-Vital signs q15min for 2 hours post-op

Question:
What is your first nursing action? *
3.1 M. Jean-François Lemoine, a 74-year-old patient, has just returned to the post-anesthesia care unit (PACU) following an abdominal laparotomy under general anesthesia. He is receiving intravenous fluids and has a patient-controlled analgesia (PCA) pump for postoperative pain management.

One hour post-op, your nursing assessment reveals:
-Pain severity: 2/10
-Level of consciousness: Drowsy
-SpO₂: 94% on room air
-Respiratory rate: 10 breaths/minute, shallow and with occasional pauses
-Blood pressure: 128/72 mm Hg
-Heart rate: 78 bpm, regular

Question:
What is the priority nursing intervention before leaving M. Lemoine's room? *
3.2 Two days after the surgery, the PCA is replaced with a prescription for hydromorphone (Dilaudid) 1mg/tab, 1 tab PO q 3-4 h PRN and acetaminophen 325 mg/tab, 2 tabs PO q4-6h PRN. In the evening, Mr. Lemoine says that the last time he took the acetaminophen was in the morning and that it didn't give him much relief. He rates his pain at 5/10 right now and asks for an analgesic.

Question:
What other information must you collect to assess the effectiveness of the medication Mr. Lemoine has taken in the last 8 hours? *
3.3 Mr. Lemoine has expressed a preference to avoid taking the prescribed opioid (hydromorphone). He reports that acetaminophen taken in the morning did not provide sufficient relief, and his current pain level is 5/10. You need to recommend a strategy for managing his pain without using the opioid medication.

Question:
Given that Mr. Lemoine refuses to take the prescribed opioid, what recommendation will you give him to help manage his pain better? *
3.4 What do you reply when Mr. Lemoine's ex-wife calls to ask when he will be discharged? *
4. Mrs. McDonald is diagnosed with a femoral head fracture. The surgery is scheduled for tomorrow morning.

At 13:15, during your assessment, you observe that Mrs. McDonald is in unbearable pain and that she says she is worried about the surgery tomorrow.

You consult the excerpt from her medication record:
-Hydromorphone (Dilaudid®) 1 mg/tab., 1 mg (1 tab.) PO q 3 h
Given at 9:00 and 12:00
-Acetaminophen (Tylenol®) 500 mg/tab. 500 mg (1 tab.) PO q 4 h PRN for pain or fever
Given at 9:00
-Hydromorphone (Dilaudid®) 2 mg/mL, 0.25 mg (0.125 mL) SC q 4 h PRN for pain
-Lorazepam (Ativan®) 0.5 mg/tab., 0.5 mg (1 tab.) SL q 6 h PRN for anxiety or insomnia

Question:
Which medication(s) will you administer? Choose TWO (2) answers. *
5. Mr. Julien Martel, a 63-year-old patient, underwent endoscopic carpal tunnel release surgery today to relieve symptoms of carpal tunnel syndrome. The procedure was completed under local anesthesia without any complications.

He is awake, alert, and stable. His surgical dressing is clean and dry, and he has tolerated fluids postoperatively. As discharge preparations are underway, his wife approaches you and asks:
“He still hasn’t peed since the surgery. Are we really allowed to go home like this?”

Question:
What is the best response? *
6.1 Ms. Cloutier, 68 years old, was admitted to the surgical unit following left hip arthroplasty. She was diagnosed with severe osteoarthritis in the shoulders and hips five years ago.

At 12:00, when she returns from the post-anesthesia care unit (recovery room), Ms. Cloutier grimaces and moans. She says that she does not have any pain in her left hip. Her neurovascular signs are appropriate, her dressing on the left hip is clean and the urinary catheter is draining straw-coloured fluid. Her intravenous solution is infusing at 80 mL/h.

Her vital signs are:
BP: 135/80 mmHg;
P: 99 beats/min., rhythm regular;
R: 22 breaths/min., rhythm regular, depth normal; SpO2: 95%;
T: 36.2°C.

Her medical record contains the following prescription:
Epidural analgesia at a flow rate of 10 mL/h. If the pain is greater than 4/10, increase the flow rate by 2 mL/h q 1 h. The maximum flow rate is at 14 mL/h.

You continue your assessment.

Question:
What are you evaluating? *
6.2 At 15:00, Ms. Cloutier says that she has had a non-radiating burning pain rated at 6/10 in her left hip for the past twenty minutes.

You complete the follow-up sheet for the epidural analgesia.
*14:00 – BP: 135/80 mmHg – P: 99/min. – R: 22/min. – SpO2: 95% – 02: None – Pain: 0/10 – Motor block (Bromage Scale): 0
*15:00 – BP: 130/80 mmHg – P: 88/min. – R: 18/min. – SpO2: 96% – 02: None – Pain: 6/10 – Motor block (Bromage Scale): 0

Bromage Scale Legend:
0 = Full flexion of knee and foot, 1 = Just able to move knee, 2 = Able to move foot only, 3 = Unable to move knee and foot.

Question:
What are you checking? *
6.3 The next day, during the change-of-shift report, your colleague says that the epidural analgesia flow rate was increased to 14 mL/h during the night and that Ms. Cloutier is well relieved.

At 08:30, Ms. Cloutier has a score of 3 on the Bromage Scale.

Her vital signs are:
BP: 106/70 mmHg;
P: 72 beats/min., rhythm regular;
R: 14 breaths/min., rhythm regular, depth normal; SpO2: 95%;
T: 37.8°C.

Bromage:
0 = Observe hourly for first 4 hours, then every 4 hours
1 = Contact pain service/physician/anesthesiologist for patient assessment and order review
2 = Stop infusion and contact pain service/physician/anesthesiologist
3 = Stop infusion and contact pain service/physician/anesthesiologist

Question:
What will you do? *
6.4 The epidural analgesia was discontinued yesterday afternoon, as prescribed. Today, at 07:45, Ms. Cloutier says that she has a burning pain rated at 4/10 in her left hip and a shooting pain rated at 2/10 in her shoulders. You consult the excerpt from Ms. Cloutier's medication administration record as well as her therapeutic nursing plan (TNP).

YESTERDAY
*Acetaminophen (TylenolTM) 325 mg/tab, 650 mg (2 tabs) PO qid – GIVEN AT = 8:00, 12:00, 18:00, 22:00
*ENOXAparin (LovenoxTM) 100 mg/mL, 40 mg (0.4 mL) subcutaneously daily – GIVEN AT = 10:00
*Pregabalin (LyricaTM) 150 mg/caps, 150 mg (1 caps) PO at bedtime – GIVEN AT = 22:00
*Morphine sulfate (MS ContinTM) 15 mg/tab, 15 mg (1 tab) PO bid – GIVEN AT = 08:00, 20:00
*Morphine sulfate (StatexTM) 5 mg/tab, 5 mg (1 tab) PO q 4 h PRN for pain – GIVEN AT = 16:00, 20:00, 23:50

TODAY:
*Acetaminophen (TylenolTM) 325 mg/tab, 650 mg (2 tabs) PO qid – TIME OF ADMINISTRATION = 8:00, 12:00, 18:00, 22:00
*ENOXAparin (LovenoxTM) 100 mg/mL, 40 mg (0.4 mL) subcutaneously daily – TIME OF ADMINISTRATION = 10:00
*Pregabalin (LyricaTM) 150 mg/caps, 150 mg (1 caps) PO at bedtime – TIME OF ADMINISTRATION = 22:00
*Morphine sulfate (MS ContinTM) 15 mg/tab, 15 mg (1 tab) PO bid – TIME OF ADMINISTRATION = 08:00, 20:00
*Morphine sulfate (StatexTM) 5 mg/tab, 5 mg (1 tab) PO q 4 h PRN for pain

THERAPEUTIC NURSING PLAN
Priority problem or need:
-Left hip arthroplasty
-Unrelieved pain in left hip

Nursing directive
-Routine follow-up for left hip arthroplasty
-Administer StatexTM 5 mg PO q 4 h regularly for 12 h

Question:
Which medication (s) will you administer? Choose Three (3) answers. *
7. Three days later, Mr. Beaulieu's general condition worsens. The attending physician meets with his children. A decision is made to change the level of medical intervention to comfort care only. The physician changes the prescriptions based on this purpose.

You review the updated medication administration form.

Medications:
*Scopolamine 0.4 mg/mL subq q 4 h PRN for bronchial rales
*Hydromorphone (Dilaudid) 2 mg/mL 0.5 mg (0.25 mL) subq q 1 h PRN for pain or dyspnea
*Midazolam (Versed) 5 mg/mL, 2.5 mg (0.5 mL) subq q 4 h PRN for agitation

Distress protocol for 3 adm. Max for 24h, administer simultaneously:
*Scopolamine 0.4 mg/mL subq q 15 min PRN
*Hydromorphone (Dilaudid) 2 mg/mL 1 mg (0.5 mL) subq 15 min PRN
*Midazolam (Versed) 5 mg/mL, 2.5 mg (0.5 mL) subq q 15 min PRN

In the bedroom, you notice that Mr. Beaulieu is holding the bed rails and moving his head from side to side continuously. His breathing is 40 breaths/min and his breathing is irregular and superficial. You decide to start the distress protocol, but Mr. Beaulieu's son, who is present at the bedside, refuses, saying: "You're going to cause him to die right away. My sister, who is the legal representative, has not yet arrived. She will be here in an hour".

Question:
What would you do? *
8. Mr. Ryan, 58 years old, had surgery today for a laparoscopic cholecystectomy. He is returned to the day surgery unit. His orders are: – Acetaminophen 300 mg with codeine 30 mg (Emtec) 2 tab. PO q 4 h PRN; – Discharge at 18:00. Appointment at outpatient surgery clinic in one month. He was given two analgesic tablets at 14:30. At 15:30, you do the monitoring required when an opioid is administered. Mr. Ryan says: “ My abdomen does not hurt as much but my right shoulder hurts, the pain is rated at 3/10.”

Question:
What do you suggest to Mr. Ryan to relieve his shoulder pain? *
9. It is 8:00 AM, Mr. Adrien Lavoie, 63 years old, had a right foot debridement for a diabetic ulcer. The wound care nurse reports that his dressing change today may be painful due to exposed tissue and recent granulation. Mr. Lavoie is anxious, stating he “remembers last time it hurt a lot.” He currently rates his pain at 4/10 at rest, but during movement or manipulation of the foot it increases to 7/10. His medication chart includes hydromorphone 1 mg PO q4h PRN for moderate to severe pain.
The dressing change is scheduled in 8:30 AM.

Question:
What should the nurse do first? *
10. Mme. Béatrice Roy, 88 years old, is receiving palliative care for end-stage heart failure. She has minimal oral intake, and her daughter is concerned that she is “not drinking enough.” The patient appears comfortable, drowsy, and not requesting fluids. You note decreased edema, reduced pulmonary crackles, and fewer episodes of coughing. Her pain score has improved from 5/10 to 2/10 with scheduled hydromorphone.

Question:
What is the best explanation to provide to the family? *
11. Mme. Nadine Ferland, 67 years old, post-hip replacement, is scheduled for physiotherapy in 45 minutes. She reports 5/10 pain at rest and 7/10 with movement. She has PRN oxycodone 5 mg PO available every 4 hours.

Question:
What should the nurse do? *
12. Mr. Samuel, 45 years old, has chronic lower back pain that worsened suddenly after lifting a heavy object. He reports sharp 7/10 pain, denies loss of sensation, and can walk slowly. He took acetaminophen two hours ago with minimal relief.

Prescription:
-Naproxen 220 mg every 8 PRN
-Acetaminophen (Tylenol) 650 mg PO q6h

Question:
What should the nurse recommend? *
13. Mr. Habib, 29 years old, presents with severe dental abscess pain radiating to the ear. He took regular acetaminophen at home without relief. He has no allergies and no respiratory compromise. The physician prescribed Tylenol #3.

Question:
What explanation should the nurse provide? *
14. Mme. Nicole Gendron, 91 years old, nearing end-of-life with metastatic cancer, is no longer able to swallow medications. She grimaces when moved and indicates pain by squeezing your hand. She has a prescription for subcutaneous hydromorphone PRN. Her mucous membranes are dry, and the family worries she is “too dehydrated.”

Question:
What is the best action (s)? Choose TWO (2) answers *
15. Mr. Adrien Chenier, 69 years old, completed treatment for shingles three weeks ago. The rash is healed, but he continues to experience burning and electric-shock pain along the right thorax, especially at night. Acetaminophen and ibuprofen have provided little to no relief. He describes the pain as “nerve pain that feels deep.” He is otherwise stable, afebrile, and fully oriented.

Question:
What medication type is most appropriate? *
16. Mme. Lorraine Villeneuve, 55 years old, is post-abdominal hysterectomy and is using a patient-controlled analgesia (PCA) pump with hydromorphone. She reports excellent control of pain (3/10 at rest, 4–5/10 with movement). Her family keeps reaching for the PCA button when they see her grimace during mobilization, saying they want her to "stay ahead of the pain."

Question:
What should the nurse explain? *
17. Mr. Patrick Duval, 73 years old, started morphine PO for chronic cancer pain. After two days, he reports abdominal fullness and decreased bowel movements. He is on no other constipating medications. His diet is normal, and he drinks adequately.

Question:
What should the nurse recommend? *
18. Mme. Florence Gauthier, 84 years old, is receiving palliative care for metastatic ovarian cancer. She is on a long-acting opioid regimen for continuous pain control but continues to have episodes of pain during movement. During repositioning, she suddenly reports intense pain rated 8/10. She is awake, breathing normally, with no signs of oversedation.

Current Medical Orders:
*Hydromorphone CR (controlled-release) 6 mg PO q12h – scheduled
*Hydromorphone IR (immediate-release) 1 mg PO q1h PRN for breakthrough pain
*Acetaminophen 650 mg PO q6h PRN for mild pain or fever
*Ondansetron 4 mg PO q8h PRN for nausea
*Do not disturb sleep unless patient requests pain medication
*Continue routine comfort measures (repositioning q2h, pressure relief, mouth care)
*Notify provider if pain remains above 6/10 despite 2 consecutive PRN doses

Question:
What is the priority intervention? *
19. Mme. Elise Parent, 62 years old, has long-standing diabetes and reports tingling, stabbing, and burning pain in both feet. She states that acetaminophen “does nothing.” She has no ulcers, and pulses are strong. Her physician has prescribed duloxetine.

Question:
What should the nurse explain? *
20. Mr. Luca Moretti, 61 years old, is post-knee replacement. He received hydromorphone IV one hour ago for severe pain. Vital signs are: RR 10/min, O2 saturation 92% on room air, he is very drowsy but arousable to voice, rating pain 2/10.

Question:
What is the nurse’s priority? *
21. Mr. Omer Bouchard, 70 years old, receiving morphine PO for cancer-related pain, reports increasing nausea and confusion. His pain remains uncontrolled at 7/10. The physician orders a switch to hydromorphone, keeping an equivalent dose.

Question:
Why is opioid rotation appropriate? *
22. Mme. Sophie Desjardins, 44 years old, is 6 hours post-laparotomy for removal of an ovarian cyst. She currently reports severe abdominal pain rated 8/10, despite having received:
*Acetaminophen 1,000 mg PO q6h PRN (last dose 2 hours ago)
*Ketorolac 15 mg IV q8h PRN (last dose 3 hours ago)

Current Post-Op Medical Orders Include:
*Hydromorphone 0.5 mg IV q3h PRN severe pain (7–10/10)
*Vital signs q1h × 12 hours then q4h
*Maintain IV NS at 75 mL/hr
*Incentive spirometer q1h while awake
*Early mobilization as tolerated
*Notify provider if HR >120, RR <10, or uncontrolled pain

Current Assessment:
She is tachycardic (HR 112/min), has shallow respirations, and refuses to mobilize due to uncontrolled pain. Non-opioid analgesics have not improved her symptoms.

Question:
What is the most appropriate nursing action? *
23. Mme. Clarisse Lemieux, 90 years old, receiving palliative care for heart failure, reports continuous pain 5–6/10 despite small doses of oral morphine. She is not overly sedated, eats little, and expresses desire for comfort. The physician orders to increase the morphine dose slightly and continue close monitoring.

Question:
What is the correct nursing action? *
24. Mr. Dominic Gervais, 50 years old, had lumbar discectomy surgery two weeks ago. He reports persistent shooting pain down the leg and numbness. The incision is clean, VS normal, no signs of infection. NSAIDs and acetaminophen have not helped. The provider prescribed pregabalin.

Question:
What explanation should the nurse give? *