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Learning Objectives
1. Identify the NCCN cancer pain guidelines to manage mild, moderate, and severe pain based on a numerical scale (0-10). 2. Using the WHO pain relief ladder, select accurate analgesic titration to manage mild, moderate, and severe pain. 3. Select appropriate strategies to manage the common side effects of opioids. 4. List appropriate patient education strategies based on the NCCN guidelines. Test Questions
#LO1 # 1. Which of the following statement (s) regarding the NCCN cancer pain guidelines is true?
A. For mild pain 1-3, you titrate short-acting opioid ± non-opioid and repeat comprehensive reassessment within 24-48 hours to meet patient goals for comfort and function. B. For moderate pain 4-6, you administer non-opioid or titrate short-acting opioid ± non-opioid and repeat comprehensive reassessment within 24-72 hours to meet patient goals for comfort and function. C. For severe pain 7-10, you rapidly titrate short-acting opioid ± non-opioid and repeat
comprehensive reassessment within 24 hours to meet patient goals for comfort and function.
D. For mild pain 1-3, you provide bowel regimen, psychosocial support, and patient/family E. All of the above
Rationale:
Correct answer: C
#LO2 # 2. A 37 year old female with breast cancer presents with severe pain in her back. She has
been taking ibuprofen around the clock with little relief. Based on the WHO pain relief ladder,
reasonable analgesic options include all of the following except:

C. Fentanyl
Page 1 of 9
E. All of the above are reasonable options. Correct answer is C
Rationale: please provide rationale
#LO3 # 3. Which of the following statement (s) regarding the management of opioids side effects is
not true?

A. If patient has delirium and opioid-Induced neurotoxicity, discontinue non-essential
psychoactive medications and use symptomatic management such as fluoxetine and
lorazepam.

B. If patient has constipation, assess for other causes and consider addition of polyethylene glycol, lactulose, magnesium hydroxide, magnesium citrate, suppository, enema, and prokinetic agent. C. If patient has nausea and vomiting, consider adding non-opioid, dose reduction, opioid rotation, or switching route of administration and use symptomatic management such as metoclopramide, haloperidol, prochlorperazine, or ondansetron. D. If patient has sedation, assess for other causes and consider adding non-opioid, dose reduction, and opioid rotation and use symptomatic management such as caffeine, methylphenidate, or modafinil. E. If patient has unarousable and/or respiratory depression, discontinue/hold opioid and use tactile stimulus and dilute naloxone 0.4 mg/mL vial with 9 mL sodium chloride 0.9% (to 0.04 mg/1 mL). Correct answer is A
Need to verify contents/ level of difficulty/answer choices Rationale: please provide rationale
#LO3 # 4. Which of the following is not a common side effect of opioid analgesics?
D. Dyspnea
Page 2 of 9
E. All of the following are common side effects of opioids. Correct answer is D
Rationale: please provide rationale
#LO4 # 5. Which of the following statement (s) is not true?
A. If pain occurs, prompt oral administration of drugs in the following order: step 1. Non opioids then, as necessary, step 2. mild opioids then, step 3. strong opioids until the patient is free of pain based on the WHO pain ladder. B. Adjuvant medications can enhance analgesic effects of other medications and be helpful treating pain syndromes. C. For patient education, you explain that addiction is rarely a problem and provide clear information about differences among addiction, physical dependence, and tolerance. D. For patient education, you explain that addiction is rarely a problem. Therefore, it is not
necessary to explain potential side effects and uncontrolled pain management.

E. Antihistamine or opioid rotation may help opioids side effects such as Itching, hives, flushing, stomach upset, nausea, and sedation. Correct answer is D
Rationale: please provide rationale
# 3. A 56 year old male patient suffers with the side effect of opioid-induced neurotoxicity.
Reasonable options for managing opioid-induced neurotoxicity include all of the following except:

D. Lorazepam
E. All of the above can be used to manage opioid-induced neurotoxicity. Page 3 of 9
Correct answer is D
Rationale: please provide rationale
Activity
LO 1 – matching games version/ or sequencing
Instruction: Drag the items on the right to corresponding description on the left.
Administer non-opioid or titrate short-acting PO opioid ± non-opioid Repeat comprehensive reassessment within 24-72 hours to meet patient goals for comfort and function Titrate short-acting opioid ± non-opioid Repeat comprehensive reassessment within 24-48 hours to meet patient goals for comfort and function Rapidly titrate short-acting opioid ± non-opioid Repeat comprehensive reassessment within 24 hours to meet patient goals for comfort and function Provide bowel regimen, psychosocial support, and patient/family education LO 1 – true/false version

Instruction: The following statements are the NCCN cancer pain guidelines regarding management of
mild, moderate, and severe pain. Please identify if statement is True or False
Page 4 of 9
1. For severe pain 7-10, administer non-opioid or titrate short-acting PO opioid ± non-opioid and repeat
comprehensive reassessment within 24-72 hours to meet patient goals for comfort and function.
True or False
Rationale: For severe pain 7-10, rapidly titrate short-acting opioid ± non-opioid and repeat
comprehensive reassessment within 24 hours to meet patient goals for comfort and function.
2. For mild pain 1-3, administer non-opioid or titrate short-acting PO opioid ± non-opioid and repeat
comprehensive reassessment within 24-72 hours to meet patient goals for comfort and function.
True or False
Rationale: please provide rationale
3. For moderate pain 4-6, rapidly titrate short-acting opioid ± non-opioid and repeat comprehensive
reassessment within 24 hours to meet patient goals for comfort and function.
True or False
Rationale: For moderate pain 4-6, titrate short-acting opioid ± non-opioid and repeat comprehensive
reassessment within 24-48 hours to meet patient goals for comfort and function
4. For all level of pain, recognize and treat side effects and provide bowel regimen, psychosocial support,
and patient/family education.
True or False
Rationale: please provide rationale
LO 2 – Case Study: Mr. Payne
LO 3 – true/false version
Instruction: The following statements are the management of opioids side effects. Please identify if
statement is True or False
1. If patient has delirium and opioid-Induced neurotoxicity, discontinue non-essential psychoactive
medications and use symptomatic management such as fluoxetine and lorazepam.
True or False
Rationale: please provide rationale
Page 5 of 9
use symptomatic management such as haloperidol, chlorpromazine, or olanzapine”
2. If patient has constipation, assess for other causes and consider addition of polyethylene glycol,
lactulose, magnesium hydroxide, magnesium citrate, suppository, enema, and prokinetic agent.
True or False
Rationale: please provide rationale
3. If patient has nausea and vomiting, consider adding non-opioid, dose reduction, opioid rotation, or
switching route of administration and use symptomatic management such as metoclopramide,
haloperidol, prochlorperazine, or ondansetron.
True or False
Rationale: please provide rationale
4. If patient has sedation, assess for other causes and consider adding non-opioid, dose reduction, and
opioid rotation and use symptomatic management such as caffeine, methylphenidate, or modafinil.
True or False
Rationale: please provide rationale
5. If patient has unarousable and/or respiratory depression, discontinue opioid and push undiluted
naloxone 0.4 mg/mL vial with 9 mL sodium chloride 0.9% (to 0.04 mg/1 mL) all at once.
True or False
Rationale: please provide rationale
“ avoid pushing undiluted naloxone 0.4 mg IV all at once except for respiratory arrest or continued hypoxia” LO 3 – multiple selection version
1. Nursing interventions for delirium and opioid-Induced neurotoxicity include:
(Select all the appropriate responses.)
Page 6 of 9
Discontinue non-essential psychoactive medications <√> Use symptomatic management such as fluoxetine and lorazepam. Exclude sepsis, metabolic derangement, or CNS involvement <√> Consider benzodiazepines to decrease neuromuscular irritability <√> Dilute naloxone 0.4 mg/mL vial with 9 mL sodium chloride 0.9% (to 0.04 mg/1 mL) Rationale: if necessary
use symptomatic management such as haloperidol, chlorpromazine, or olanzapine”
2. Nursing interventions for constipation include:
(Select all the appropriate responses.)
Consider addition of polyethylene glycol, lactulose, magnesium hydroxide, magnesium citrate, suppository, enema, and prokinetic agent <√> Use symptomatic management such as haloperidol, chlorpromazine, or olanzapine
Administer stimulant laxative (senna) ± stool softener (docusate sodium) <√> Rule out obstruction and check for impaction <√> Rationale: if necessary
3. Nursing interventions for nausea and vomiting include:
(Select all the appropriate responses.)
Consider adding non-opioid, dose reduction, opioid rotation <√> Switching route of administration <√> Page 7 of 9
Use symptomatic management such as metoclopramide, haloperidol, prochlorperazine, or Use symptomatic management such as caffeine, methylphenidate, or modafinil Consider scheduling antiemetic around the clock for 1 week, then change to PRN <√> Rationale: if necessary
4. Nursing interventions for sedation include:
(Select all the appropriate responses.)
Consider adding non-opioid, dose reduction, and opioid rotation <√> Dilute naloxone 0.4 mg/mL vial with 9 mL sodium chloride 0.9% (to 0.04 mg/1 mL) Use symptomatic management such as caffeine, methylphenidate, or modafinil <√> Rationale: if necessary
5. Nursing interventions for unarousable and/or respiratory depression include:
(Select all the appropriate responses.)
Use symptomatic management such as caffeine, methylphenidate, or modafinil Avoid pushing undiluted naloxone 0.4 mg IV all at once except for respiratory arrest or continued Page 8 of 9
Dilute naloxone 0.4 mg/mL vial with 9 mL sodium chloride 0.9% (to 0.04 mg/1 mL) <√> Rationale: if necessary
“avoid pushing undiluted naloxone 0.4 mg IV all at once except for respiratory arrest or continued hypoxia” LO 4 – patients/caregivers education Activity
In teaching patients/caregivers about pharmacologic intervention, topics to review include: (Select all the appropriate responses.)
Pain can usually be well controlled with medications taken by mouth. <√> If opioids are taken now, they will still work later. <√> Do not mix alcohol or illicit substances or operate heavy machinery. <√> Addiction is rarely a problem and provide clear information about differences among addiction, physical dependence, and tolerance. <√> It is not necessary advice patient/caregiver to report unmanageable side effects or uncontrolled Rationale: if necessary
Page 9 of 9

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