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) “Aspirin can cause gastrointestinal bleeding.”
This is because aspirin is a salicylate that works by reducing substances in the body that cause pain, fever, and inflammation, but also prevents blood clots from forming in the arteries.This can increase the risk of bleeding, especially in the stomach or gut.
Choice A) “Aspirin can be taken with alcohol.” is wrong because alcohol can also increase the risk of bleeding and interact with aspirin.
Choice B) “Aspirin can be taken on an empty stomach.” is wrong because aspirin can irritate the stomach lining and cause heartburn, nausea, or vomiting.It is better to take aspirin with food or water.
Choice C) “Aspirin can be taken with antacids.” is wrong because antacids can reduce the effectiveness of aspirin and interfere with its absorption.It is better to avoid taking antacids within two hours of taking aspirin.
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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