A nurse is caring for a client who has a sickle cell crisis and is receiving morphine via patient-controlled analgesia (PCA) pump.

Which assessment finding indicates that the PCA pump is effective?

The client reports a pain level of 4 on a scale of 0 to 10.

The client has a respiratory rate of 12 breaths per minute.

The client has a blood pressure of 140/90 mm Hg.

The client has a pulse oximetry reading of 95%.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. The client reports a pain level of 4 on a scale of 0 to 10. This indicates that the PCA pump is effective in reducing the client’s pain, which is the primary symptom of sickle cell crisis.

Choice B is wrong because a respiratory rate of 12 breaths per minute is normal and does not indicate the effectiveness of the PCA pump.

Choice C is wrong because a blood pressure of 140/90 mm Hg is high and may indicate hypertension, which is a complication of sickle cell disease.

Choice D is wrong because a pulse oximetry reading of 95% is normal and does not indicate the effectiveness of the PCA pump.

Normal ranges for vital signs are:

• Respiratory rate: 12-20 breaths per minute

• Blood pressure: <120/80 mm Hg

• Pulse oximetry: >95%

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Correct Answer is ["A","C","E"]

Explanation

The correct answer is choice A, C and E. These statements indicate that the client understands the teaching about nonpharmacological pain management techniques.

• Choice A is correct becausemeditationcan help the client relax and cope with pain by reducing stress and anxiety.

• Choice C is correct becausedistractioncan help the client divert attention from pain by engaging in enjoyable or stimulating activities.

• Choice E is correct becauseheatcan help the client soothe the painful area by increasing blood flow and relaxing muscles.

• Choice B is wrong becausecold packsshould not be applied to the painful area for more than15 minutesat a time, as they can cause tissue damage or frostbite.

• Choice D is wrong becausemassageshould not be done with firm pressure, as it can aggravate the pain or cause injury.Gentle massage may be beneficial for some clients.

A. Serum calcium B. Serum potassium C. Serum creatinine D. Serum albumin

Correct Answer is A

Explanation

The correct answer is choice A. Serum calcium.Etidronate is a bisphosphonate that inhibits bone resorption and reduces the risk of skeletal complications in patients with cancer-related bone pain.However, it can also cause hypocalcemia (low serum calcium levels) as a side effect, which can lead to muscle spasms, numbness, tingling, seizures, and cardiac arrhythmias.

Therefore, the nurse should monitor the patient’s serum calcium levels regularly and supplement with calcium and vitamin D if needed.

Choice B. Serum potassium is wrong because etidronate does not affect potassium levels.Potassium is mainly regulated by the kidneys and can be altered by renal impairment, dehydration, acid-base imbalance, or medications such as diuretics or potassium-sparing agents.

Choice C. Serum creatinine is wrong because etidronate does not affect creatinine levels.

Creatinine is a waste product of muscle metabolism that is excreted by the kidneys.It reflects the glomerular filtration rate (GFR) and can be elevated in renal dysfunction or dehydration.

Choice D. Serum albumin is wrong because etidronate does not affect albumin levels.

Albumin is a protein that is synthesized by the liver and helps maintain fluid balance and transport substances in the blood.It can be decreased in liver disease, malnutrition, inflammation, or protein-losing conditions.

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A nurse is caring for a client who has a sickle cell crisis and is receiving morphine via patient-controlled analgesia (PCA) pump. Which assessment finding indicates that the PCA pump is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has chronic pain about nonpharmacological pain management techniques. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

A patient with cancer-related bone pain is receiving etidronate as an adjuvant analgesic. The nurse should monitor the patient for which of the following laboratory values?

Correct Answer is A

Explanation

A client with osteoarthritis has been prescribed celecoxib (Celebrex). The nurse should instruct the client to report which of the following adverse effects immediately?

Which statement made by a client taking aspirin indicates an understanding of its use?

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?

Which component of pain assessment is addressed by asking a client to rate his or her current level of discomfort on a scale of 0-10?

A nurse is reviewing laboratory results for a client who takes acetaminophen for osteoarthritis pain management.Which of the following findings should alert the nurse to possible hepatotoxicity? (Select all that apply.).

A nurse is educating a client about ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), that has been prescribed for moderate pain and inflammation. Which of the following instructions should the nurse include? (Select all that apply.).

A nurse is caring for a patient who has been prescribed fentanyl patches for chronic cancer pain management at home. Which statement by the patient indicates that he understands how to use this medication safely?

A nurse is caring for a client who has a sickle cell crisis and is receiving morphine via patient-controlled analgesia (PCA) pump.

Which assessment finding indicates that the PCA pump is effective?