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 D
Explanation
The correct answer is choice D. The patient will experience improved mental status and oxygenation.This is because naloxone is a medication that can rapidly reverse an opioid overdose by blocking the effects of opioids and restoring normal breathing.Naloxone can be given as a nasal spray or an injection.
Choice A is wrong because naloxone does not increase euphoria and sedation, but rather reverses them by blocking opioid receptors.
Choice B is wrong because naloxone does not cause severe withdrawal symptoms and agitation, but rather mild to moderate ones that are not life-threatening.
Choice C is wrong because naloxone does not decrease respiratory rate and blood pressure, but rather increases them by reversing opioid overdose.
Normal ranges for respiratory rate are 12 to 20 breaths per minute and for blood pressure are 90/60 mmHg to 120/80 mmHg.
Correct Answer is B
Explanation
The correct answer is choice B. Check the client’s allergy history.
This is because morphine sulfate is a medication that can cause severe allergic reactions in some people, such as anaphylaxis, which can be life-threatening.
Therefore, the nurse should always check the client’s allergy history before administering any medication, especially opioids.
Choice A is wrong because assessing the client’s respiratory rate is not the first action the nurse should take.
Although morphine sulfate can cause respiratory depression, which is a serious side effect that needs to be monitored, the nurse should first ensure that the client is not allergic to the medication.
Choice C is wrong because reviewing the client’s medication record is not the first action the nurse should take.
Although morphine sulfate can interact with other medications, such as sedatives, antidepressants, or alcohol, which can increase the risk of respiratory depression or overdose, the nurse should first ensure that the client is not allergic to the medication.
Choice D is wrong because verifying the dosage with another nurse is not the first action the nurse should take.
Although morphine sulfate is a high-alert medication that requires double-checking to prevent medication errors, the nurse should first ensure that the client is not allergic to the medication.
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