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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Calculation:
Volume to administer = Dose ordered/ Dose available
Given:
- Ordered dose = 75 mg
- Available concentration = 50 mg/mL
Volume = 75mg/ (50mg/mL)
= 1.5mL
Thus, the nurse will administer 1.5 mL.
Correct Answer is D
Explanation
A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.
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