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","E"]
Explanation
The correct answer is choice A, B, C, and E. The nurse should use the following strategies to assess this client’s pain:
• Ask yes or no questions: This can help the client to communicate their pain level and location with minimal language difficulty.
• Use a visual analog scale (VAS): This is a self-report pain scale that uses a line with endpoints labeled as “no pain” and “worst pain imaginable”.The client can point to a position on the line that corresponds to their pain intensity.VAS has been shown to be feasible, valid, and reliable for stroke patients with mild-to-moderate aphasia.
• Observe for nonverbal cues: This can include facial expressions, body movements, vocalizations, and changes in vital signs that may indicate pain.Nonverbal cues are especially important for clients with severe aphasia who cannot use self-report scales.
• Involve family members or caregivers: They can provide information about the client’s pain history, preferences, and behaviors that may indicate pain.They can also help the nurse to communicate with the client and interpret their responses.
Choice D is wrong because open-ended questions require more complex language skills and may frustrate the client with aphasia.The nurse should use simple and direct questions that can be answered with yes or no, gestures, or pointing.
Correct Answer is B
Explanation
The correct answer is choice B.Methadone blocks the euphoric effects of heroin and discourages its use.Methadone is a synthetic opioid analgesic that produces a cross-tolerance to other narcotics, thereby preventing the user from feeling the high of heroin.Methadone also reduces withdrawal symptoms and cravings for heroin.
Choice A is wrong because methadone does not prevent withdrawal symptoms, but rather reduces them.
Choice C is wrong because methadone does not stimulate opioid receptors, but rather occupies them and blocks their activation by heroin.
Choice D is wrong because methadone does not reverse the respiratory depression caused by heroin overdose, but rather carries a risk of overdose itself.
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