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. Serum creatinine B. Serum potassium C. Serum albumin D. Serum bilirubin.

Correct Answer is D

Explanation

The correct answer is choice D. Serum bilirubin.The nurse should monitor the client’s serum bilirubin level closely because acetaminophen, a non-opioid analgesic, can cause hepatotoxicity and acute liver failure in cases of overdose.

Serum bilirubin is a marker of liver function and damage.

A high level of serum bilirubin indicates jaundice, a sign of liver injury.

Choice A is wrong because serum creatinine is a marker of kidney function and damage.Acetaminophen has limited nephrotoxicity compared to NSAIDs.

Choice B is wrong because serum potassium is not directly affected by acetaminophen.

Serum potassium is an electrolyte that reflects fluid and acid-base balance in the body.

Choice C is wrong because serum albumin is a protein that is synthesized by the liver.

Although serum albumin may be low in chronic liver disease, it is not a sensitive indicator of acute liver injury caused by acetaminophen overdose.

Normal ranges for serum bilirubin are 0.3 to 1.2 mg/dL for adults and 1 to 12 mg/dL for newborns.

Normal ranges for serum creatinine are 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women.

Normal ranges for serum potassium are 3.5 to 5 mEq/L for adults and children.

Normal ranges for serum albumin are 3.4 to 5.4 g/dL for adults and children.

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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 nurse is caring for a client who has been prescribed acetaminophen, a non-opioid analgesic, for mild pain. Which laboratory test result should the nurse monitor closely in this client?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who has a prescription for acetaminophen and hydrocodone (Vicodin).Which of the following instructions should the nurse include in the teaching?

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.)

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

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.

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.)