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","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.
Correct Answer is D
Explanation
The correct answer is choice D. The patient will experience improved mental status and oxygenation.This is because naloxone is a medication that can rapidly reverse an opioid overdose by blocking the effects of opioids and restoring normal breathing.Naloxone can be given as a nasal spray or an injection.
Choice A is wrong because naloxone does not increase euphoria and sedation, but rather reverses them by blocking opioid receptors.
Choice B is wrong because naloxone does not cause severe withdrawal symptoms and agitation, but rather mild to moderate ones that are not life-threatening.
Choice C is wrong because naloxone does not decrease respiratory rate and blood pressure, but rather increases them by reversing opioid overdose.
Normal ranges for respiratory rate are 12 to 20 breaths per minute and for blood pressure are 90/60 mmHg to 120/80 mmHg.
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