A nurse is assessing the status of a patient who is sleeping.
Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

Decreased respirations, rapid heart rate.

Rapid respirations, rapid heart rate.

Rapid respirations, slow heart rate.

Decreased respirations, slow heart rate.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Decreased respirations and a rapid heart rate are not indicative of stage 3 of non-rapid eye movement (NREM) sleep. In stage 3, respirations are typically slow and regular, and the heart rate is slower than during wakefulness.

Choice B rationale:

Rapid respirations and a rapid heart rate are indicative of stage 3 of NREM sleep. During this stage, respiration and heart rate are more irregular compared to the earlier stages of sleep. This stage is characterized by increased physiological arousal compared to stages 1 and 2.

Choice C rationale:

Rapid respirations and a slow heart rate do not represent stage 3 of NREM sleep. In this stage, respiration tends to be rapid, and the heart rate, while slower than during wakefulness, is not slow.

Choice D rationale:

Decreased respirations and a slow heart rate are not consistent with stage 3 of NREM sleep. This stage is associated with more active and variable physiological processes, including rapid respirations and a relatively higher heart rate compared to later sleep stages.

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Correct Answer is B

Explanation

Choice A rationale:

This statement is not accurate and may confuse the client. In a Patient-Controlled Analgesia (PCA) system, a predetermined dose is delivered when the patient activates the device. The dose is usually controlled to prevent excessive medication administration.

Choice B rationale:

This statement is correct. The essence of PCA is that the patient has control over administering their pain medication within set limits or time intervals. The patient can self-administer doses when needed, ensuring effective pain management.

Choice C rationale:

Allowing the partner to push the PCA button for the patient is not recommended. PCA systems are designed to be controlled by the patient themselves to prevent potential overdosing. Involving someone else in the administration can lead to safety concerns.

Choice D rationale:

PCA systems do not deliver medication into the muscle. They typically deliver medication intravenously (IV) or subcutaneously. This statement is inaccurate and could lead to misconceptions about how the PCA system works.

A. The client has an elevated blood pressure. B. The client is asleep. C. The client has an increased respiratory rate. D. The client is diaphoretic.

Correct Answer is C

Explanation

Choice A rationale:

An elevated blood pressure is not a reliable indicator of a decrease in pain following the administration of an opioid narcotic. Blood pressure can be influenced by various factors, and it may not directly correlate with the relief of pain.

Choice B rationale:

The client being asleep is not a direct indicator of decreased pain following opioid administration. While opioids may cause drowsiness as a side effect, the absence of pain cannot be confirmed solely based on the patient's sleep state.

Choice C rationale:

An increased respiratory rate can be a reliable indicator of decreased pain following the administration of an opioid narcotic. Opioids often cause respiratory depression, so an increased respiratory rate may suggest that the patient's pain is adequately managed, as they are not experiencing excessive respiratory depression.

Choice D rationale:

Diaphoresis (excessive sweating) is not a direct indicator of decreased pain following opioid administration. Diaphoresis can be caused by various factors, including anxiety, and may not specifically reflect pain relief. .

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A nurse is assessing the status of a patient who is sleeping.Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about using a PCA for postoperative pain management.Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is assessing the status of a patient who is sleeping.
Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?