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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale:
Increasing pain over several hours is not a typical sign of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose symptoms often involve respiratory depression, altered mental status, and other serious issues. While it is possible for a patient to experience increased pain if the fentanyl patch is not providing adequate pain relief, this is not a specific sign of overdose.
Choice B rationale:
An itchy red rash on the skin is not a sign of a fentanyl patch overdose but can be associated with skin irritation or allergies to the adhesive in the patch. It's important to differentiate between a skin reaction and an overdose when evaluating patients using fentanyl patches. Overdose symptoms are more severe and life-threatening.
Choice C rationale:
Confusion and the inability to walk normally are characteristic signs of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose can lead to central nervous system depression, resulting in confusion, altered mental status, and difficulty with coordination and walking. These symptoms are serious and require immediate medical attention.
Choice D rationale:
Headache and nausea are not specific signs of a fentanyl patch overdose. While opioid overdose can cause various symptoms, such as respiratory depression and altered mental status, headache and nausea are not among the primary indicators. However, individual responses to medications can vary, and some patients may experience these symptoms as part of a broader set of overdose signs.
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