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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.

A. Take the temperature for 6-8 minutes B. Wear gloves throughout the procedure C. Place the patient in the prone position D. Insert the thermometer 2.5 inches into the patient's anus

Correct Answer is B

Explanation

A. Take the temperature for 6-8 minutes. Modern digital thermometers provide accurate readings within seconds to a minute, making such a long duration unnecessary.
B. Wear gloves throughout the procedure. Gloves must be worn to maintain infection control and hygiene, as rectal temperature measurement involves contact with mucous membranes and potential exposure to bodily fluids.
C. Place the patient in the prone position. The left lateral (Sims') position is the preferred position for rectal temperature measurement, as it provides better access and comfort.
D. Insert the thermometer 2.5 inches into the patient's anus. For adults, the correct insertion depth is 1.5 inches (3-4 cm), while for infants, it is only 0.5 inches (1.3 cm) to prevent injury.

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A postoperative patient is using patient-controlled analgesia (PCA) pump. You will evaluate the effectiveness of the medication when

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are assessing a client who has the following vital signs: blood pressure 120/68, pulse 84, respirations 18. You should:

Correct Answer is B

Explanation

The nurse must take a patient's rectal temperature. Which should the nurse do?

Correct Answer is B

Explanation

Which instruction will the nurse give to the patient about proper use of patient-controlled analgesia (PCA)?

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