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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Apical. The apical pulse, located at the apex of the heart, provides the most accurate measurement of heart rate, especially in patients with irregular rhythms. It is assessed by auscultation with a stethoscope over the fifth intercostal space at the midclavicular line.
B. Radial. The radial pulse is commonly used for routine pulse checks, but it may be less accurate in cases of irregular heart rhythms or weak peripheral circulation.
C. Brachial. The brachial pulse is typically used in infants and for blood pressure measurements, but it is not the most accurate method for assessing heart rate.
D. Popliteal. The popliteal pulse is located behind the knee and is used to assess circulation to the lower extremities, not for measuring heart rate accurately.

A. "The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts." B. "The numbers are within normal range and nothing to worry about." C. The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure." D. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart."

Correct Answer is A

Explanation

A. "The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts." The systolic pressure (118 mmHg) represents the force exerted on the arterial walls when the heart contracts and pumps blood.
B. "The numbers are within normal range and nothing to worry about." While 118/82 mmHg is within the normal range, this response does not explain what the numbers mean, which was the patient’s question.
C. "The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure." While the systolic pressure is important, the diastolic pressure is also crucial for assessing cardiovascular health. This response also discourages patient education.
D. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." Diastolic pressure (82 mmHg) represents the pressure in the arteries when the heart is at rest, not stroke volume, which refers to the amount of blood ejected per heartbeat.

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A postoperative patient is using patient-controlled analgesia (PCA) pump. You will evaluate the effectiveness of the medication when

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which method will provide the most accurate measurement of the patient's heart rate?

Correct Answer is A

Explanation

Your patient's blood pressure is 118/82. He asks you to explain "what the numbers mean." You reply:

Correct Answer is A

Explanation

The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse's responsibility regarding delegation of this task?

Which assessment requires the nurse to assess the patient further?

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