ANCC Pain Management Nursing 1 — Questions and Answers
Question 1: A patient with chronic low back pain (7/10) takes oxycodone 10 mg every 4 hours plus acetaminophen. Which WHO analgesic ladder step does this represent?
- Step 1: Non-opioid analgesics only
- Step 2: Mild-to-moderate opioids plus non-opioids
- Step 3: Strong opioids plus non-opioids with or without adjuvants (Correct answer)
- Step 4: Interventional pain management
Correct answer: Step 3: Strong opioids plus non-opioids with or without adjuvants
Oxycodone is a strong opioid, placing this regimen at WHO Step 3 — for moderate-to-severe pain using strong opioids (morphine, oxycodone, hydromorphone, fentanyl) with or without non-opioids and adjuvants.
WHO Analgesic Ladder: Step 1 (mild pain NRS 1-3) uses non-opioids (acetaminophen, NSAIDs) with adjuvants; Step 2 (mild-to-moderate pain NRS 4-6) uses mild/weak opioids (codeine, tramadol, low-dose oxycodone or hydrocodone) plus non-opioids; Step 3 (moderate-to-severe pain NRS 7-10) uses strong opioids (morphine, oxycodone, hydromorphone, fentanyl, methadone) plus non-opioids with or without adjuvants. Adjuvants include TCAs, anticonvulsants (gabapentin, pregabalin), corticosteroids, muscle relaxants, and topical agents.
Question 2: A patient on chronic opioid therapy develops nausea, vomiting, diarrhea, sweating, and severe anxiety 12 hours after their last dose. This is most consistent with:
- Opioid overdose requiring naloxone
- Opioid withdrawal syndrome (Correct answer)
- Serotonin syndrome from opioid-antidepressant interaction
- Opioid-induced hyperalgesia
Correct answer: Opioid withdrawal syndrome
Opioid withdrawal presents with autonomic hyperactivity (sweating, tachycardia) and GI symptoms (nausea, vomiting, diarrhea) beginning 8-24 hours after last dose of short-acting opioids.
Opioid withdrawal timeline: short-acting opioids have onset 8-24 hours, peak 36-72 hours, duration 5-7 days; long-acting opioids (methadone) have onset 36-48 hours, peak 72-96 hours, duration 2 or more weeks. Clinical features: tachycardia, hypertension, diaphoresis, piloerection (goosebumps), mydriasis (dilated pupils), yawning, rhinorrhea, nausea, vomiting, diarrhea, abdominal cramps, bone/joint aching, restlessness, anxiety, insomnia. Management: methadone or buprenorphine, clonidine (alpha-2 agonist), loperamide, ondansetron. Contrast with overdose: miosis (pinpoint pupils), CNS depression, respiratory depression — NOT GI hyperactivity.
Question 3: A FLACC assessment shows grimacing (face 2), legs drawn up (legs 2), rigid body (activity 2), crying continuously (cry 2), and inconsolable (consolability 2). Total score and clinical meaning?
- Total score 8: moderate pain
- Total score 10: severe pain requiring immediate intervention (Correct answer)
- Total score 6: mild-to-moderate pain
- Total score 10: sedation-related symptoms, not pain
Correct answer: Total score 10: severe pain requiring immediate intervention
FLACC scores each of 5 categories 0-2 with maximum total = 10. A score of 10 (2+2+2+2+2) indicates severe pain requiring immediate pharmacological and non-pharmacological intervention.
FLACC (Face, Legs, Activity, Cry, Consolability): validated for infants/children 2 months to 7 years and non-verbal patients. Each category scored 0-2: 0 = no indicators; 1 = occasional/intermittent; 2 = frequent/constant. Score interpretation: 0 = relaxed/comfortable; 1-3 = mild discomfort; 4-6 = moderate pain; 7-10 = severe pain. A score of 10 requires immediate intervention: assess for new pathology, administer prescribed analgesic, apply non-pharmacological measures, and reassess within 30-60 minutes. Document pre- and post-intervention scores.
Question 4: A patient with cancer pain is starting extended-release morphine. Which order must also be provided at initiation of scheduled opioid therapy?
- Routine laxative (senna or docusate) to prevent opioid-induced constipation (Correct answer)
- Naloxone for routine administration every 6 hours
- Antiemetic prophylaxis scheduled around the clock for 30 days
- Dose reduction of all other analgesics to avoid polypharmacy
Correct answer: Routine laxative (senna or docusate) to prevent opioid-induced constipation
Opioid-induced constipation (OIC) is the most universal and persistent opioid side effect — tolerance does NOT develop. A stimulant laxative (senna) must be prescribed prophylactically when initiating opioid therapy.
Opioid side effect management: Constipation requires mandatory stimulant laxative (senna with or without docusate) — fiber/bulking agents are ineffective for OIC; tolerance does NOT develop; methylnaltrexone or naloxegol for refractory OIC. Nausea/vomiting: PRN antiemetics; tolerance usually develops within 1-2 weeks so indefinite scheduled prophylaxis is not required. Sedation: usually resolves with tolerance. Respiratory depression: naloxone available for rescue but not routine scheduled administration. Starting opioids without a laxative is a standard of care violation.
Question 5: A patient is prescribed hydromorphone 0.4 mg IV every 4 hours. Available concentration is 2 mg/mL. How many mL per dose?
- 0.4 mL
- 0.2 mL (Correct answer)
- 2 mL
- 4 mL
Correct answer: 0.2 mL
Volume = Dose divided by Concentration = 0.4 mg divided by 2 mg/mL = 0.2 mL. Hydromorphone is approximately 5-10 times more potent than morphine; careful dose verification is essential.
Calculation: desired dose 0.4 mg; available concentration 2 mg/mL; volume = 0.4 / 2 = 0.2 mL. Hydromorphone (Dilaudid) is approximately 5-7 times more potent than morphine IV. High-alert medication requiring independent double-check, BCMA, and smart pump drug library. ISMP and The Joint Commission identify concentrated opioids as high-alert medications. Many institutions use 1 mg/mL for standard dosing to reduce very small volume calculation errors.
Question 6: Which combination of analgesic modalities best represents a multimodal analgesia approach for a post-surgical patient?
- Morphine PCA alone titrated to pain level
- Scheduled acetaminophen, scheduled NSAIDs (if not contraindicated), gabapentin, and opioids only as needed (Correct answer)
- Two different opioids prescribed simultaneously for synergy
- Maximizing opioid doses before adding non-opioid adjuvants
Correct answer: Scheduled acetaminophen, scheduled NSAIDs (if not contraindicated), gabapentin, and opioids only as needed
Multimodal analgesia combines analgesics and techniques with different mechanisms to provide superior pain relief at lower opioid doses, reducing opioid-related side effects.
Multimodal analgesia (MMA) rationale: combining different mechanisms produces additive or synergistic analgesia at lower individual doses, reducing opioid consumption by 30-50% and associated side effects. ERAS protocol includes: acetaminophen (centrally-acting, non-opioid foundation) scheduled; NSAIDs if no contraindications; gabapentinoids to reduce central sensitization; regional anesthesia and nerve blocks; opioids reserved as PRN rescue. Two opioids simultaneously increases respiratory depression risk without analgesic advantage.
ANCC Pain Management Nursing 1
A patient with chronic low back pain (7/10) takes oxycodone 10 mg every 4 hours plus acetaminophen.
Which WHO analgesic ladder step does this represent?