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%.
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%
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C.The patient should remove the old patch before applying a new one to avoid overdose and adverse effects of fentanyl.Fentanyl patches are designed to deliver a constant amount of opioid analgesic over a period of time, usually 72 hours.
Therefore, changing the patch every other day (choice A) would result in inadequate pain relief and withdrawal symptoms.
Applying the patch to a hairy area (choice B) would interfere with the absorption of the drug and reduce its effectiveness.
Cutting the patch in half (choice D) would damage the integrity of the patch and cause erratic or rapid release of the drug, which could be fatal.Fentanyl patches should be applied to a clean, dry, hairless area of intact skin on the upper torso or upper arm.
Correct Answer is C
Explanation
The correct answer is choice C) Chest pain.
This is because chest pain can be a sign of a serious cardiovascular event, such as a heart attack or stroke, which can be fatal.
Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that belongs to the class of cyclooxygenase-2 (COX-2) inhibitors.These drugs can increase the risk of cardiovascular thrombotic events, especially in patients with a history of heart disease or risk factors.
Therefore, the nurse should instruct the client to report chest pain immediately and seek emergency medical attention.
Choice A) Constipation is wrong because it is not a common or serious side effect of celecoxib.
Constipation can be caused by many factors, such as diet, dehydration, lack of exercise, or other medications.It can be managed by increasing fluid and fiber intake, using laxatives or stool softeners as needed, and consulting a doctor if it persists or worsens.
Choice B) Nausea is wrong because it is a common but mild side effect of celecoxib that usually goes away with time or can be reduced by taking the medication with food or milk.
Nausea is not a sign of a serious adverse reaction and does not require immediate medical attention.
Choice D) Headache is wrong because it is also a common but mild side effect of celecoxib that can be treated with over-the-counter pain relievers, such as acetaminophen or ibuprofen.
However, the client should avoid taking aspirin or other NSAIDs with celecoxib, as this can increase the risk of gastrointestinal bleeding and ulcers
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