A nurse is caring for a client who has a sickle cell crisis and is receiving morphine via patient-controlled analgesia (PCA) pump.
Which assessment finding indicates that the PCA pump is effective?
The client reports a pain level of 4 on a scale of 0 to 10.
The client has a respiratory rate of 12 breaths per minute.
The client has a blood pressure of 140/90 mm Hg.
The client has a pulse oximetry reading of 95%.
The Correct Answer is A
The correct answer is choice A. The client reports a pain level of 4 on a scale of 0 to 10. This indicates that the PCA pump is effective in reducing the client’s pain, which is the primary symptom of sickle cell crisis.
Choice B is wrong because a respiratory rate of 12 breaths per minute is normal and does not indicate the effectiveness of the PCA pump.
Choice C is wrong because a blood pressure of 140/90 mm Hg is high and may indicate hypertension, which is a complication of sickle cell disease.
Choice D is wrong because a pulse oximetry reading of 95% is normal and does not indicate the effectiveness of the PCA pump.
Normal ranges for vital signs are:
• Respiratory rate: 12-20 breaths per minute
• Blood pressure: <120/80 mm Hg
• Pulse oximetry: >95%
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
The correct answer is choice A, C and E. These statements indicate that the client understands the teaching about nonpharmacological pain management techniques.
• Choice A is correct becausemeditationcan help the client relax and cope with pain by reducing stress and anxiety.
• Choice C is correct becausedistractioncan help the client divert attention from pain by engaging in enjoyable or stimulating activities.
• Choice E is correct becauseheatcan help the client soothe the painful area by increasing blood flow and relaxing muscles.
• Choice B is wrong becausecold packsshould not be applied to the painful area for more than15 minutesat a time, as they can cause tissue damage or frostbite.
• Choice D is wrong becausemassageshould not be done with firm pressure, as it can aggravate the pain or cause injury.Gentle massage may be beneficial for some clients.
Correct Answer is A
Explanation
The correct answer is choice A.Blurred vision is a common side effect of gabapentin and should be reported to the doctor.
Blurred vision can affect the patient’s ability to perform daily activities and may indicate a serious problem with the eyes or the brain.
Choice B is wrong because constipation is not a common side effect of gabapentin.
Constipation can be caused by other factors such as diet, dehydration, or lack of physical activity.
Choice C is wrong because dry mouth is a common side effect of gabapentin and does not usually require medical attention.
Dry mouth can be relieved by drinking water, chewing sugar-free gum, or using saliva substitutes.
Choice D is wrong because tinnitus is not a common side effect of gabapentin.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by many conditions such as ear infections, hearing loss, or exposure to loud noises.
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