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%.

Answer and Explanation

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%

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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.

A. Respiratory rate: 10 breaths/min B. Blood pressure: 110/70 mm Hg C. Heart rate: 72 beats/min D. Temperature: 37°C.

Correct Answer is A

Explanation

The correct answer is choice A) Respiratory rate: 10 breaths/min.This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.

Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.

The normal respiratory rate for adults is 12 to 20 breaths/min.

Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg.Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.

Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min.Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.

Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans.Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.

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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?

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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?