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. Intensity.Intensity is one of the key components of pain assessmentand it is measured by asking a client to rate his or her current level of discomfort on a scale of 0-10.

This helps to quantify the severity of pain and monitor its changes over time.

Choice B. Quality is wrong because quality refers to the nature or characteristics of pain, such as burning, stabbing, throbbing, etc.It is usually assessed by asking the client to describe the pain in his or her own words.

Choice C.Onset is wrong because onset refers to the time when the pain started or what triggered it.It is usually assessed by asking the client about the mechanism of injury or etiology of pain, if identifiable.

Choice D.Duration is wrong because duration refers to how long the pain lasts or how often it occurs.It is usually assessed by asking the client about the course or temporal pattern of pain, such as constant, intermittent, or episodic.

A. Elevated aspartate aminotransferase (AST) B. Elevated alanine aminotransferase (ALT) C. Elevated alkaline phosphatase (ALP) D. Elevated blood urea nitrogen (BUN) E. Elevated creatinine.

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

Explanation

The correct answer is choice A, B, and C. These are all liver enzymes that can indicate hepatotoxicity (liver damage) from acetaminophen overdose.

The normal ranges for these enzymes are:

• AST: 10 to 40 U/L

• ALT: 7 to 56 U/L

• ALP: 45 to 115 U/L

Choice D and E are wrong because they are indicators of renal function, not liver function.

The normal ranges for these values are:

• BUN: 7 to 20 mg/dL

• Creatinine: 0.6 to 1.2 mg/dL

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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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Naxlex Comprehensive Predictor Exams

Which component of pain assessment is addressed by asking a client to rate his or her current level of discomfort on a scale of 0-10?

Correct Answer is A

Explanation

A nurse is reviewing laboratory results for a client who takes acetaminophen for osteoarthritis pain management.Which of the following findings should alert the nurse to possible hepatotoxicity? (Select all that apply.).

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

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?