A nurse is assessing the status of a patient who is sleeping.
Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

Decreased respirations, rapid heart rate.

Rapid respirations, rapid heart rate.

Rapid respirations, slow heart rate.

Decreased respirations, slow heart rate.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Decreased respirations and a rapid heart rate are not indicative of stage 3 of non-rapid eye movement (NREM) sleep. In stage 3, respirations are typically slow and regular, and the heart rate is slower than during wakefulness.

Choice B rationale:

Rapid respirations and a rapid heart rate are indicative of stage 3 of NREM sleep. During this stage, respiration and heart rate are more irregular compared to the earlier stages of sleep. This stage is characterized by increased physiological arousal compared to stages 1 and 2.

Choice C rationale:

Rapid respirations and a slow heart rate do not represent stage 3 of NREM sleep. In this stage, respiration tends to be rapid, and the heart rate, while slower than during wakefulness, is not slow.

Choice D rationale:

Decreased respirations and a slow heart rate are not consistent with stage 3 of NREM sleep. This stage is associated with more active and variable physiological processes, including rapid respirations and a relatively higher heart rate compared to later sleep stages.

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Correct Answer is C

Explanation

Choice A rationale:
The primary care provider (PCP) is responsible for prescribing the PCA but does not typically program the PCA pump. The PCP may set the initial parameters for the PCA, such as the dose and lockout interval, but the actual programming and operation of the PCA pump is typically carried out by the nursing staff.
Choice B rationale:
Pharmaceutical companies manufacture and provide medications, including the medications used in PCA, but they do not program PCA pumps. Programming and administration of the PCA are nursing responsibilities.
Choice D rationale:
Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN) can assist in the administration and monitoring of PCA, but they do not typically program the PCA pump. Registered nurses are usually responsible for the programming and operation of PCA pumps.

A. Pain is assessed only for patients who complain of pain. B. Pain treatment ends at discharge. C. All patients have the right to appropriate assessment of pain. D. Pain treatment is based on objective data collected by the nurse.

Correct Answer is C

Explanation

Choice A rationale:

False. Pain should not be assessed only for patients who complain of pain. Pain assessment should be a routine part of patient care, as not all patients may be able to verbalize their pain or may underreport it. Identifying and addressing pain is crucial for patient well-being.

Choice B rationale:

False. Pain treatment does not necessarily end at discharge. The management of pain may continue beyond the hospital setting, and a plan for pain management post-discharge may be needed. This ensures that patients receive appropriate pain relief and support during their recovery.

Choice C rationale:

True. According to the Joint Commission's standards, all patients have the right to appropriate assessment of pain. This means that every patient, regardless of their condition or the presence of pain complaints, should have their pain assessed and managed as necessary.

Choice D rationale:

False. Pain treatment is not solely based on objective data collected by the nurse. Pain is a subjective experience, and it is essential to consider the patient's self-report of pain, in addition to any objective data, when determining the appropriate treatment. Objective data can help, but it should not be the sole basis for pain management.

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A nurse is assessing the status of a patient who is sleeping.Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse takes into consideration that when the patient has an order for patient-controlled analgesia (PCA), the pump will be programmed by the:

Correct Answer is C

Explanation

The nurse takes into consideration the Joint Commission on Accreditation of Healthcare Organizations (CAHO) standards for pain assessment and treatment. Include:.

Correct Answer is C

Explanation

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A nurse is assessing the status of a patient who is sleeping.
Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep?