Editing Fundamentals of Nursing – RN Flashcards (section)

== Pain, sleep, and elimination ==

;What is the most reliable indicator of pain?
:The patient's self report. Normal vital signs never disprove pain, because autonomic responses habituate in persistent pain.

;Which pain assessment tool matches which patient?
:The 0 to 10 numeric rating scale for most adults, Wong Baker FACES for children roughly three years and older, FLACC for infants and nonverbal children, and PAINAD or the Critical Care Pain Observation Tool for adults who cannot self report, such as those with advanced dementia or on mechanical ventilation.

;What is the earliest warning sign of opioid induced respiratory depression, and which side effect never resolves with tolerance?
:Increasing sedation is the earliest warning sign and precedes respiratory depression. Constipation is the effect to which tolerance does not develop, so a bowel regimen begins when the opioid begins.

;What is the central safety principle of patient controlled analgesia?
:Only the patient presses the button. The patient's own sedation is the built in dose limit, so proxy dosing by family or staff removes the safeguard and can cause oversedation.

;Which sleep stage is most restorative, and how does aging change sleep?
:Non rapid eye movement stage N3 slow wave sleep is the most physically restorative and predominates early in the night. Older adults need a similar total sleep time but obtain less N3, wake more frequently, and shift toward earlier sleep and wake times.

;What is the minimum acceptable adult urine output?
:About 30 milliliters per hour, or 0.5 milliliters per kilogram per hour. Sustained output below this threshold must be reported.

;What are the key nursing measures to prevent catheter associated urinary tract infection?
:Insert only when indicated and remove as early as possible, use sterile insertion technique, maintain a closed system, secure the tubing, keep the bag below the bladder and off the floor, avoid dependent loops, sample from the port, and avoid routine irrigation.

;What is the classic presentation of fecal impaction?
:Frequent small amounts of liquid stool leaking around a hardened mass, often mistaken for diarrhea, typically in an immobile patient or a patient receiving opioids. Treating it with antidiarrheals worsens the impaction.