A nurse is caring for a patient who is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?

Respiratory rate: 10 breaths/min

Blood pressure: 110/70 mm Hg

Heart rate: 72 beats/min

Temperature: 37°C.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A) Respiratory rate: 10 breaths/min. This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.

Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.

The normal respiratory rate for adults is 12 to 20 breaths/min.

Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg. Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.

Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min. Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.

Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans. Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.

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Correct Answer is A

Explanation

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%

A. Use a standard pain assessment tool B. Increase features of the scale, such as font size C. Repeat instructions and questions more than once D. Ask about present level of pain rather than pain history D. Ask about present level of pain rather than pain history E. Allow ample time for the patient to respond (Source: https://quizlet.com/129952120/pain-assessment-hesi-flash-cards/).

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

Explanation

The correct answer is choice A, B, C and E.These actions by the nurse help facilitate the pain assessment by using a consistent and clear method to measure the patient’s pain level, enhancing the visibility and understanding of the scale, repeating the information for clarity and accuracy, and giving the patient enough time to respond without rushing or interrupting.

Choice D is wrong because asking about the present level of pain rather than the pain history is more relevant for pain management, not the pain assessment.The pain history provides valuable information about the onset, duration, frequency, quality, intensity, location, and aggravating or relieving factors of the pain.

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A nurse is caring for a patient who is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.

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

Explanation

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?

A patient with cancer-related bone pain is receiving etidronate as an adjuvant analgesic. The nurse should monitor the patient for which of the following laboratory values?

A nurse is educating a patient who has been prescribed aspirin for the prevention of cardiovascular events. Which of the following instructions should the nurse include? (Select all that apply.)

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.).

A nurse is caring for a patient who has been prescribed fentanyl patches for chronic cancer pain management at home. Which statement by the patient indicates that he understands how to use this medication safely?

(Select all that apply) A patient with postoperative pain is prescribed hydroxyzine as an adjuvant analgesic. The nurse should teach the patient about which of the following benefits of this medication.

A nurse is caring for an older adult client who has difficulty communicating verbally due to aphasia following a stroke. Which of the following strategies should the nurse use to assess this client’s pain? (Select all that apply.)

A nurse is caring for a client who has chronic hepatitis C and reports taking acetaminophen daily for headaches.The nurse should monitor the client for which of the following adverse effects?