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","B","C","D"]
Explanation
The correct answer is choice A, B, C, and D.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that has anti-inflammatory, analgesic, and antipyretic effects.It works by inhibiting the synthesis of prostaglandins, which are involved in inflammation, pain, and fever.However, ibuprofen can also cause adverse effects such as gastric irritation, bleeding complications, renal impairment, and hypersensitivity reactions.
Therefore, the nurse should instruct the client to:
• Take ibuprofen with food or milk to prevent gastric irritation.This will reduce the direct contact of the drug with the stomach lining and decrease the risk of ulcers and bleeding.
• Drink at least 2 liters of fluid per day to prevent renal impairment.This will help maintain adequate hydration and renal perfusion and prevent the accumulation of ibuprofen in the kidneys.
• Avoid alcohol and other NSAIDs to prevent bleeding complications.Alcohol and other NSAIDs can increase the risk of gastric bleeding by interfering with the protective effects of prostaglandins on the stomach mucosa.
• Report any signs of hypersensitivity such as rash, itching, or wheezing.These may indicate an allergic reaction to ibuprofen that can be serious or life-threatening.
Choice E is wrong because ibuprofen does not affect blood pressure significantly.However, some other NSAIDs such as celecoxib may increase the risk of cardiovascular events such as thrombosis, myocardial infarction, and stroke.Therefore, clients with hypertension or cardiovascular disease should use NSAIDs with caution and monitor their blood pressure regularly.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.These actions by the nurse help facilitate the pain assessment by using a consistent and clear method to measure the patient’s pain level, enhancing the visibility and understanding of the scale, repeating the information for clarity and accuracy, and giving the patient enough time to respond without rushing or interrupting.
Choice D is wrong because asking about the present level of pain rather than the pain history is more relevant for pain management, not the pain assessment.The pain history provides valuable information about the onset, duration, frequency, quality, intensity, location, and aggravating or relieving factors of the pain.
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