NCLEX-RN cheat sheet · Comfort and pain
Pain and opioids
Assessment, pain scales, comfort measures, opioids, naloxone and non-opioids
AI-checkedChecked by AI against current guidelines, with spot-checks by a registered nurse.
Believe the client's pain report, assess fully, reassess after every intervention. Opioids are among the most dangerous drugs nurses give.
Download the free PDF: Pain and opioids, 2 pages
Two printable pages, free. No sign-up.
At a glance
Acute or chronic
| Acute | Chronic | |
|---|---|---|
| Timing | Short-term, with a clear cause | Persists or recurs for over 3 months, or beyond expected healing |
| Vital signs | Often raises pulse, breathing and BP | Usually doesn't change them |
| Also | Tense muscles, low energy, poor appetite, depression, anger, fear of getting hurt again |
Believe the client: Normal vital signs don't mean there's no pain. Neuropathic pain, from nerve damage, often feels like burning, or pins and needles.
Match the scale to the client
| Client | Scale |
|---|---|
| Alert adult | Numeric 0 to 10: 0 is no pain, 10 the worst imaginable |
| Child generally 3 or older, or can't use numbers | Wong-Baker FACES, if they understand the instructions. Pointing alone isn't enough |
| Infant or young child, or can't report pain | FLACC: face, legs, activity, cry, consolability; each 0 to 2, total 0 to 10 |
| Advanced dementia | PAINAD: breathing, vocal sounds, facial expression, body language, consolability |
Screen, then assess: A 0 to 10 rating is a screen, not a full assessment: follow it with PQRSTU.
Opioids
| Key points | |
|---|---|
| Morphine dose | Moderate to severe pain. No fixed ceiling, but sedation, respiratory depression and individual response limit the dose. Higher doses may not bring more relief; opioid-induced hyperalgesia can worsen pain. Lowest effective dose; escalate to the prescriber |
| Breathing | First 24 to 72 hours, and after a dose increase. Highest risk: older or frail, COPD, low oxygen, airway problems |
| Other sedatives | With benzodiazepines, alcohol or other sedating drugs: profound sedation, coma and death |
| Other effects | Low BP, dizziness, sedation, nausea, sweating, constipation: track bowel function |
| Also | Can hide the signs of a head injury (pupils, consciousness); not given with a bowel obstruction. Can trigger seizures, biliary spasm. Reduced doses: enlarged prostate, severe kidney or liver disease, underactive thyroid |
PCA and fentanyl patches
| Key points | |
|---|---|
| PCA | Only the client presses: a sleepy client who can't press it is a built-in safety check |
| PCA lockout | Limits dose frequency, but overdose is still possible: basal infusions, programming or concentration errors, other sedatives. Keep monitoring breathing and sedation |
| Fentanyl patch | Only for opioid-tolerant clients with severe, ongoing pain; never for new, short-term pain. Worn up to 72 hours |
| Patch safety | No heat on or near it (heating pad, fever): can release a fatal dose. Check every new medicine. Falls off? Fold it sticky sides together. Flush it at home; in a facility, waste it per policy. Apply a new one elsewhere |
Naloxone
- Reverses opioid sedation and respiratory depression. IV usually works within 2 minutes; IM starts a little slower but lasts longer.
- It can wear off before the opioid: sleepiness and slow breathing can return, and repeat doses are often needed. Keep watching.
- Opioid-dependent client: sudden withdrawal within minutes (aches, sweating, yawning, shivering, restlessness, fast pulse). It usually eases within about 2 hours.
Non-opioids and adjuvants
| Drug | Key points |
|---|---|
| Acetaminophen | Pain and fever, not inflammation. Over 4,000 mg a day in adults can cause severe liver damage; lower limits for older adults and heavy drinkers. Count every source, combination pills too. Antidote: acetylcysteine |
| NSAIDs (ibuprofen) | Pain, fever, inflammation. Boxed warnings: heart attack, stroke; serious stomach bleeding, especially after a past ulcer or bleed |
| Ketorolac | Limited to 5 days in adults. Not with advanced kidney disease, dehydration, or for pain after heart bypass surgery |
| Aspirin | Stomach bleeding, ringing ears, severe allergy. Reye's syndrome in children or teens with or after flu or chickenpox |
| Adjuvants | Gabapentin, amitriptyline: nerve pain; first gabapentin dose at bedtime. Taper baclofen. Cyclobenzaprine: drowsiness, dry mouth, urinary retention |
Assess with PQRSTU
- P: what provokes or relieves it. Q: quality, like aching, stabbing or burning.
- R: region, and whether it spreads. S: severity, often 0 to 10.
- T: timing, and treatment tried so far. U: understanding: what does the client think is causing it?
- Use open questions and clarify mismatches: "tolerable" but rates it 7? Ask more.
Comfort without medication
- Use alone or with medication; choose with the client. Distraction, relaxation, music, a calm environment, repositioning, TENS.
- Massage 3 to 5 minutes, never over red or swollen areas.
- Heat or cold: thin towel between the pack and the skin. Never heat over a medication patch; for implants, follow device guidance. Client can't tell you? Check the skin every 5 minutes.
One textbook range: Heat 5 to 20 minutes, cold no longer than 20. Timing depends on the device, skin integrity, sensation, perfusion and care plan.
Priority and safety calls
- Assess pain with a scale before and after every dose, and ask what level the client finds acceptable.
- Vomiting? An oral dose may not work: choose the best route.
- Drowsy with slow breathing after naloxone: stimulate, support breathing, prepare to repeat naloxone per orders, keep monitoring.
- Family pressing the PCA button: explain that only the client presses it; sleepiness is a safety check.
- Teach: no driving, no alcohol or other sedating drugs. Crushing, chewing, snorting or injecting an opioid can cause a fatal overdose.
- Reassess every intervention once it should have taken effect: pain, function and side effects. Document the response.
- Evaluate every analgesic: reassess pain and function, and watch breathing, blood pressure and the bowels.
- Assistive personnel report pain they notice, and can be delegated repositioning, heat or cold.
How the NCLEX tests it
- Normal vital signs don't rule out pain: believe the client.
- Advanced dementia: PAINAD, not a number scale.
- No heat over a medication patch; with a fentanyl patch, heat can release a fatal dose.
- Naloxone can wear off before the opioid: don't leave after one dose.
- Fentanyl patches are for opioid-tolerant clients, not new pain.
- Add up acetaminophen from every product over 24 hours, combination pills included.
- Ketorolac is limited to 5 days in adults.
Practice it next
This sheet comes from Pain assessment and nonpharmacological comfort and Pain management and reversal agents in our NCLEX-RN course. Try free practice questions, or see the lessons it was written from.
Quick self-quiz
- Chronic pain persists or recurs for over ___ months.
Show answer
3 - For advanced dementia, use the ___ scale.
Show answer
PAINAD - Each FLACC item scores 0 to ___.
Show answer
2 - Opioid respiratory depression is most likely in the first 24 to ___ hours.
Show answer
72 - Given IV, naloxone usually works within ___ minutes.
Show answer
2 - The antidote for an acetaminophen overdose is ___.
Show answer
acetylcysteine
Sources
- Open RN, Nursing Pharmacology 2e, 10.7 Opioid Analgesics and Antagonists
- Open RN, Nursing Fundamentals 2e, 11.3 Pain Assessment Methods
- Open RN, Nursing Fundamentals 2e, 11.4 Pain Management
- Open RN, Nursing Pharmacology 2e, 10.6 Non-Opioid Analgesics
- IASP, Preventing Pain: An Introduction (fact sheet)
- Wong-Baker FACES Foundation
- DailyMed, Fentanyl Transdermal System label
- DailyMed, Naloxone Hydrochloride Injection label
More comfort and pain cheat sheets
Educational use only. This sheet is a study aid for the NCLEX-RN, not a substitute for clinical judgment, your facility’s policy or the provider’s orders. Where practice varies, follow facility policy and state law. NCLEX® and NCLEX-RN® are registered trademarks of NCSBN, which does not endorse these materials.