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 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.

A. Monitor the patient’s vital signs regularly. B. Encourage fluid intake and high-fiber foods. C. Advise the patient to avoid alcohol and other CNS depressants. D. Instruct the patient to take acetaminophen (Tylenol) for breakthrough pain. E. Teach the patient how to use a patient-controlled analgesia (PCA) pump.

Correct Answer is ["B","C"]

Explanation

The correct answer is choice B and C.Oxycodone (OxyContin) is a potent opioid analgesic that can causeconstipation,drowsiness,nausea,pruritus, andvomitingas common side effects.

To prevent constipation, the patient should be encouraged to drink plenty of fluids and eat high-fiber foods.To prevent respiratory depression and sedation, the patient should be advised to avoid alcohol and other CNS depressants while taking oxycodone.

Choice A is wrong because monitoring vital signs regularly is not specific to oxycodone use, but rather a general nursing intervention for any patient with chronic pain.

Choice D is wrong because acetaminophen (Tylenol) can interact with oxycodone and increase the risk of liver damage.

The patient should not take any other pain medications without consulting the prescriber.

Choice E is wrong because a patient-controlled analgesia (PCA) pump is not used for long-term pain management, but rather for acute or postoperative pain.Oxycodone (OxyContin) is formulated as an extended-release tablet that provides sustained pain relief for up to 12 hours.

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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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Explanation

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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?