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","C","E"]

Explanation

The correct answer is choice A, C and E. These statements indicate that the client understands the teaching about nonpharmacological pain management techniques.

• Choice A is correct becausemeditationcan help the client relax and cope with pain by reducing stress and anxiety.

• Choice C is correct becausedistractioncan help the client divert attention from pain by engaging in enjoyable or stimulating activities.

• Choice E is correct becauseheatcan help the client soothe the painful area by increasing blood flow and relaxing muscles.

• Choice B is wrong becausecold packsshould not be applied to the painful area for more than15 minutesat a time, as they can cause tissue damage or frostbite.

• Choice D is wrong becausemassageshould not be done with firm pressure, as it can aggravate the pain or cause injury.Gentle massage may be beneficial for some clients.

A. Assess the client’s respiratory rate. B. Check the client’s allergy history. C. Review the client’s medication record. D. Verify the dosage with another nurse.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has chronic pain about nonpharmacological pain management techniques. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

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

Explanation

The nurse is preparing to administer morphine sulfate, an opioid analgesic, to a client who reports pain at level 8 on a scale of 0 to 10. Which action should the nurse take first?

Correct Answer is B

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?