Pain control spans multiple domains, heavily impacting the 40 scored items in Patient/Care Management. You must know how to safely administer opioids, manage PCA pumps, and assess non-verbal patients. Test your knowledge with these free CMSRN questions from our bank of 4100+ items.
Question 1
26 of 125. A patient with opioid use disorder (OUD) recovering for 90 days reports severe incision pain. The resident orders half the standard morphine dose. Which advocacy action is most appropriate?
- A) A) Administer the reduced dose to minimize relapse risk
- B) B) Suggest naloxone co-administration per hospital policy
- C) C) Request pain management consultation for multimodal analgesia✓
- D) D) Advocate for the standard dose with increased monitoring
Show rationale
Multimodal approaches optimize pain control while reducing opioid exposure in OUD, aligning with ASAM guidelines. Option A risks undertreatment. Option B is inappropriate without overdose signs. Option D increases relapse risk without specialized input. Advocacy requires balancing adequate relief with addiction risks through expert consultation.
Question 2
27 of 125. A nurse discovers a PCA pump programmed with a 1 mg hydromorphone demand dose instead of the ordered 0.2 mg. The patient received one dose 15 minutes ago and is currently alert. What action follows institutional RCA protocols?
- A) A) Notify pharmacy and risk management after assessing the patient✓
- B) B) Discontinue the PCA and monitor for sedation every 5 minutes
- C) C) Reprogram the PCA correctly and document the error internally
- D) D) Administer naloxone prophylactically per overdose guidelines
Show rationale
A 500% dosing error requires root cause analysis (RCA) per Joint Commission Sentinel Event guidelines. Immediate patient assessment ensures safety, but reporting initiates system-level review. Reprogramming (C) alone neglects required error documentation processes. Discontinuing PCA (B) is unnecessary if the patient is stable post-single dose. Naloxone (D) is indicated for symptoms, not prophylaxis. Alertness suggests observation suffices, but reporting is mandatory.
Question 3
31 of 125. A 68-year-old patient with severe osteoarthritis and obstructive sleep apnea (OSA) using CPAP at home is started on morphine PCA post-hip replacement. Four hours later, the nurse notes respiratory rate of 8/min, oxygen saturation 89% on room air, and sedation score of 3 (difficult to arouse). Which intervention is most appropriate?
- A) A) Administer naloxone 0.4 mg IV push immediately
- B) B) Stimulate the patient and apply supplemental oxygen via nasal cannula✓
- C) C) Discontinue morphine PCA and increase IV fluid rate
- D) D) Obtain arterial blood gas and notify anesthesia stat
Show rationale
Stimulation and oxygen address acute respiratory depression while avoiding abrupt opioid reversal risks (ASPMN guidelines). OSA increases vulnerability, but naloxone (A) may cause abrupt withdrawal and isn't first-line for partial response. Discontinuing PCA (C) doesn't resolve hypoxia. ABGs (D) delays intervention; oxygenation takes priority over diagnostics. Sedation score 3 cues moderate compromise requiring immediate non-pharmacologic rescue before escalation.
Question 4
97 of 125. A 78-year-old patient with advanced dementia is admitted for pneumonia. The daughter reports her mother winces during turning but the nurse documents "no pain behaviors observed." Vital signs are stable. Which action best demonstrates advocacy for pain control?
- A) A) Document the daughter's report and reassess using the PAINAD scale during care activities✓
- B) B) Administer scheduled acetaminophen as ordered and monitor for sedation
- C) C) Request a geriatric consult to evaluate the patient's pain expression patterns
- D) D) Educate the daughter about dementia-related pain perception changes
Show rationale
The key advocacy action integrates collateral information (daughter's report) with standardized assessment (PAINAD) for non-verbal patients per ASPMN guidelines. Option B ignores observational assessment. Option C delays immediate evaluation despite available tools. Option D dismisses the family's valid concern rather than investigating. Stable vital signs don't rule out pain in dementia, requiring behavioral assessment tools.
Question 5
58 of 125. Post-hip-replacement day 3, a patient rates pain 7/10 on movement. They have a history of chronic back pain managed with yoga. Current pain is described as "sharp" and "localized." Which pain assessment tool is most clinically relevant?
- A) A) Oswestry Disability Index for functional impact
- B) B) Brief Pain Inventory for multidimensional assessment
- C) C) Visual Analog Scale for acute surgical pain intensity✓
- D) D) McGill Pain Questionnaire for sensory descriptors
Show rationale
Acute postoperative pain requires simple intensity tracking for rapid intervention. Option C provides real-time quantification for titration per orthopedic protocols. Option A assesses chronic disability, not acute surgical pain. Option B is comprehensive but time-consuming for acute care. Option D details descriptors but doesn't prioritize intensity measurement. Discriminators include recent surgery, movement-triggered pain, and the clinical need for efficient intensity monitoring in acute settings.
Question 6
64 of 125. An elderly patient with dementia and hip fracture exhibits agitation and grimacing during movement. The PAINAD score is 6/10. Which approach best assesses and manages suspected pain?
- A) A) Administer lorazepam 0.5mg IV and reassess behaviors in 30 minutes
- B) B) Give scheduled acetaminophen 650mg q6h with PRN oxycodone for physical therapy✓
- C) C) Apply heat therapy and reposition before offering PRN tramadol
- D) D) Start melatonin at bedtime with PRN haloperidol for agitation episodes
Show rationale
Scheduled acetaminophen provides baseline analgesia for persistent pain, while PRN opioids target movement-related breakthrough pain. PAINAD scores >4 indicate moderate pain requiring pharmacological intervention. Option A uses anxiolytics not analgesics. Option C delays pharmacological treatment. Option D addresses sleep/agitation but not nociceptive pain. Guidelines recommend scheduled non-opioids + PRN opioids for acute pain in dementia with validated behavioral assessment.
Question 7
71 of 125. A patient with opioid use disorder (in remission 6 months) requires analgesia for traumatic fractures. Current methadone dose is 80mg/day. Which approach optimizes pain control while supporting recovery?
- A) A) Provide PRN oxycodone at standard doses alongside scheduled methadone
- B) B) Continue methadone and add scheduled acetaminophen with tramadol PRN
- C) C) Increase methadone by 20% divided doses and add non-opioid adjuncts✓
- D) D) Discontinue methadone and initiate fentanyl PCA with addiction consult
Show rationale
Methadone provides baseline analgesia for OUD patients; increasing it by ≤20% (per CDC) avoids withdrawal while managing acute pain. Divided doses improve coverage, and non-opioids reduce opioid exposure. PRN oxycodone (A) risks relapse. Tramadol (B) has serotonergic risks and is contraindicated with methadone. Abrupt methadone discontinuation (D) precipitates withdrawal. AMSN guidelines emphasize maintaining OUD treatment with multimodal analgesia.
Question 8
96 of 125. A 68-year-old with severe COPD (FEV1 45% predicted) and OSA uses nocturnal CPAP is prescribed morphine PCA post-laparotomy. Oxygen saturation is 94% on 2L NC. Thirty minutes after initiation, the patient's respiratory rate decreases to 8/min with shallow breaths. Which action takes precedence?
- A) A) Administer naloxone per standing order protocol
- B) B) Increase oxygen flow rate to 4L via nasal cannula immediately
- C) C) Discontinue PCA pump and stimulate patient to breathe deeply✓
- D) D) Obtain arterial blood gas analysis to confirm hypoventilation
Show rationale
Discontinuing PCA removes the opioid source causing respiratory depression, and stimulation assesses responsiveness—critical first steps per ASA guidelines. Increasing oxygen (B) risks masking hypoventilation in COPD patients and doesn't address the opioid effect. Naloxone (A) is premature before minimizing opioid exposure and assessing arousal. ABG (D) delays intervention for acute respiratory compromise. Age, COPD severity, and shallow breathing are cues for rapid opioid cessation over diagnostics.
Question 9
110 of 125. A postoperative patient from a culture valuing stoicism rates pain 8/10 but refuses medication, stating "I don't want to bother anyone." Which approach demonstrates culturally responsive advocacy?
- A) A) Respect the refusal but offer non-pharmacological options like repositioning✓
- B) B) Administer PRN analgesics covertly in intravenous fluids
- C) C) Explain that unrelieved pain will delay discharge
- D) D) Document refusal and reassess in 30 minutes
Show rationale
This honors cultural values while actively addressing pain through alternative methods, aligning with AMSN advocacy principles. Option B violates autonomy. Option C uses coercion inconsistent with advocacy. Option D is passive and fails to address barriers. Cultural competence requires adapting approaches without overriding patient preferences.
Question 10
34 of 125. Oncology patient on transdermal fentanyl for bone pain reports three breakthrough pain episodes daily. Current rescue dose is morphine 10mg PO q2h PRN. Which modification is MOST appropriate?
- A) A) Increase fentanyl patch strength by 25 mcg/hr at next scheduled change✓
- B) B) Add scheduled gabapentin and continue current PRN morphine dosing
- C) C) Change rescue opioid to fentanyl buccal tablet 200 mcg PRN
- D) D) Administer morphine 10mg IV instead of PO for breakthrough pain
Show rationale
≥3 breakthrough doses/day indicates inadequate baseline control. Titrating fentanyl by 25 mcg/hr (per FDA) addresses this while matching delivery routes. Buccal fentanyl (C) is for breakthrough pain but doesn't correct baseline underdosing. Adding gabapentin (B) is adjunctive but not primary for opioid-responsive pain. IV morphine (D) increases overdose risk without improving absorption efficiency. AMSN guidelines recommend scheduled opioid titration before modifying breakthrough regimens.
Question 11
54 of 125. A 68-year-old patient with severe COPD and obstructive sleep apnea is receiving morphine PCA after abdominal surgery. Which assessment parameter requires the MOST frequent monitoring during the first 24 hours postoperatively?
- A) A) Blood pressure every 2 hours and after each PCA dose
- B) B) Oxygen saturation via continuous pulse oximetry with hourly respiratory rate✓
- C) C) Pain intensity score using a 0-10 scale every 4 hours
- D) D) Sedation level using the Pasero Opioid-Induced Sedation Scale every shift
Show rationale
Patients with COPD and sleep apnea have high opioid-induced respiratory depression risk. Continuous SpO2 detects hypoxemia early, and hourly respiratory rate identifies bradypnea. While pain scores (C) are important, respiratory status takes priority. Blood pressure (A) is less critical than airway compromise. Sedation scales (D) are essential but don't replace respiratory monitoring; every-shift checks are insufficient. CMSRN guidelines emphasize continuous respiratory monitoring for high-risk patients on IV opioids.
Question 12
79 of 125. A 68-year-old Vietnamese patient with metastatic bone cancer rates pain as 8/10 but refuses morphine, stating it "isn't necessary." The nurse notes stoic demeanor and family nodding in agreement. Which barrier most likely explains this response?
- A) A) Fear of opioid addiction due to media portrayal of substance abuse
- B) B) Cultural beliefs about enduring pain without complaint✓
- C) C) Lack of insurance coverage for prescribed analgesics
- D) D) Concerns about medication side effects impairing cognition
Show rationale
The key cues—Vietnamese heritage, stoicism, family agreement, and refusal despite high pain—indicate cultural norms valuing quiet endurance. Option A lacks supporting evidence (no media mention). Option C is unsupported (insurance not discussed). Option D focuses on side effects without patient expression of cognitive concerns. Cultural competence standards (ANA) emphasize recognizing cultural pain expression variations. Distractors miss cultural context cues.
Question 13
99 of 125. During opioid taper for a construction worker with chronic pain and high-dose dependence, which intervention prioritizes safety while minimizing withdrawal?
- A) A) Discontinuing opioids abruptly with clonidine for symptom control
- B) B) Reducing dose by 50% weekly with PRN benzodiazepines for anxiety
- C) C) Decreasing dose 10% weekly with scheduled buprenorphine transition✓
- D) D) Maintaining current dose with added NSAIDs for functional goals
Show rationale
Slow tapers (5-20% weekly) prevent severe withdrawal (CDC). Buprenorphine treats dependence with lower overdose risk. Option A risks severe withdrawal and job impairment. Option B’s rapid taper causes instability; benzodiazepines increase fall risk for laborers. Option D avoids necessary taper. Key cues: high-dose dependence (physiological risk) and physical job (safety priority). Buprenorphine’s partial agonism provides safer withdrawal management.
Question 14
113 of 125. An asthmatic patient with aspirin-exacerbated respiratory disease (AERD) requires analgesia post-hemorrhoidectomy. Which analgesic minimizes bronchospasm risk?
- A) A) Ketorolac 15 mg intravenous every 6 hours
- B) B) Acetaminophen 1000 mg oral every 6 hours✓
- C) C) Ibuprofen 600 mg oral every 6 hours
- D) D) Naproxen 500 mg oral every 12 hours
Show rationale
Acetaminophen is safest as it doesn't inhibit COX-1, avoiding prostaglandin imbalances that trigger bronchospasm in AERD. All NSAIDs (A, C, D) block COX-1 and can cause life-threatening asthma exacerbations, per AAAAI guidelines. Ketorolac (A) is high-risk due to IV administration speeding onset. Ibuprofen (C) and naproxen (D) have strong COX-1 inhibition. Distractors ignore AERD history; B aligns with respiratory safety and postoperative pain needs without cross-reactivity.
Question 15
73 of 125. A post-op patient with intellectual disability flaps hands and vocalizes loudly when approached. Their caregiver states, "This is their happy behavior." Which action best validates pain presence?
- A) A) Compare current behavior to caregiver's baseline report✓
- B) B) Administer analgesia for presumed procedural pain
- C) C) Use FLACC scale based on observed agitation
- D) D) Defer assessment until the patient calms spontaneously
Show rationale
Caregiver input is critical for interpreting behaviors in intellectual disability. Discerning deviations from baseline (e.g., "happy" vs. distressed vocalizations) identifies pain-related changes. Administering analgesics without validation risks sedation. FLACC may misinterpret self-stimulatory behaviors as pain. Deferring assessment prolongs potential suffering. Individualized behavior assessment, supported by collateral history, aligns with IASP recommendations for neurodiverse populations.