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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Intensity.Intensity is one of the key components of pain assessmentand it is measured by asking a client to rate his or her current level of discomfort on a scale of 0-10.
This helps to quantify the severity of pain and monitor its changes over time.
Choice B. Quality is wrong because quality refers to the nature or characteristics of pain, such as burning, stabbing, throbbing, etc.It is usually assessed by asking the client to describe the pain in his or her own words.
Choice C.Onset is wrong because onset refers to the time when the pain started or what triggered it.It is usually assessed by asking the client about the mechanism of injury or etiology of pain, if identifiable.
Choice D.Duration is wrong because duration refers to how long the pain lasts or how often it occurs.It is usually assessed by asking the client about the course or temporal pattern of pain, such as constant, intermittent, or episodic.
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.
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