A postoperative patient is using patient-controlled analgesia (PCA) pump. You will evaluate the effectiveness of the medication when
Family members report that pain has subsided
Vital signs have returned to baseline
Body language is incongruent with reports of pain relief
You compare assessed pain with baseline pain
The Correct Answer is D
A. Family members report that pain has subsided. Pain is a subjective experience, and the patient's own report is the most reliable indicator of pain relief, not the observations of family members.
B. Vital signs have returned to baseline. While pain can affect vital signs, such as increasing heart rate or blood pressure, their return to normal does not necessarily indicate adequate pain relief. Some patients may still experience significant pain despite stable vital signs.
C. Body language is incongruent with reports of pain relief. Nonverbal cues can be helpful in assessing pain, but they should not override the patient’s self-reported pain level, which is the most accurate measure.
D. You compare assessed pain with baseline pain. The best way to evaluate the effectiveness of PCA analgesia is to assess the patient’s pain level before and after medication administration, comparing it to baseline pain. This provides an objective measure of pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 200/92. This format does not include the muffling point (Phase IV), which is important in some clinical settings, such as in critically ill patients or those with vascular diseases.
B. 100/200/92. This order is incorrect because the systolic pressure should always be listed first, followed by the diastolic components.
C. 200/100. This format omits the point at which sounds completely disappear (Phase V), which is the true diastolic pressure in most cases. However, in some individuals, particularly those with conditions like aortic regurgitation, the muffling point may be recorded as an additional reading.
D. 200/100/92. The correct way to document blood pressure when Korotkoff sounds muffle before disappearing is to include all three values: the systolic pressure (Phase I), the point of muffling (Phase IV), and the diastolic pressure (Phase V). This ensures a complete and accurate blood pressure recording.
Correct Answer is A
Explanation
A. "The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts." The systolic pressure (118 mmHg) represents the force exerted on the arterial walls when the heart contracts and pumps blood.
B. "The numbers are within normal range and nothing to worry about." While 118/82 mmHg is within the normal range, this response does not explain what the numbers mean, which was the patient’s question.
C. "The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure." While the systolic pressure is important, the diastolic pressure is also crucial for assessing cardiovascular health. This response also discourages patient education.
D. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." Diastolic pressure (82 mmHg) represents the pressure in the arteries when the heart is at rest, not stroke volume, which refers to the amount of blood ejected per heartbeat.
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