A nurse is collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?
Bradycardia.
Decreased respiratory rate.
Hypoglycemia.
Hypertension.
The Correct Answer is D
Choice A rationale:
Bradycardia, a slow heart rate, is not typically associated with acute pain. In response to pain, the body usually experiences increased heart rate (tachycardia) as part of the stress response.
Choice B rationale:
A decreased respiratory rate is not an expected finding in response to acute pain. Acute pain often leads to increased respiratory rate as the body attempts to manage the pain and stress.
Choice C rationale:
Hypoglycemia, a low blood sugar level, is not a typical physiological response to acute pain. Acute pain is more likely to induce a release of stress hormones, such as cortisol and adrenaline, which can lead to increased blood sugar levels.
Choice D rationale:
Hypertension, or elevated blood pressure, is an expected physiological response to acute pain. Pain activates the body's stress response, leading to increased sympathetic nervous system activity, which can cause vasoconstriction and increased blood pressure. This response helps prepare the body to cope with the pain and stress. Monitoring blood pressure in a client reporting acute pain is essential to assess the impact of pain and determine appropriate pain management strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The CPAP device should not fit loosely on the face. It should fit snugly to create a proper seal and maintain positive airway pressure. A loose-fitting CPAP mask may not effectively treat obstructive sleep apnea (OSA).
Choice B rationale:
The CPAP device typically delivers consistent pressure throughout both inhalation and exhalation. It does not deliver less pressure during exhalation. The purpose of CPAP is to maintain a constant pressure to keep the airway open during both phases of the respiratory cycle.
Choice C rationale:
The CPAP device does not require an invasive ventilation tube. It uses a mask that covers the nose or both the nose and mouth to deliver positive airway pressure. It is non-invasive and is designed to keep the airway open by delivering pressurized air.
Correct Answer is C
Explanation
Choice C rationale:
The most crucial instruction regarding the safety of fentanyl patches is to apply them as directed by the primary care provider. Fentanyl is a potent opioid medication, and its misuse or improper application can lead to serious health risks, including overdose. Therefore, following the prescriber's instructions is of utmost importance to ensure the patient's safety.
Choice A rationale:
Storing fentanyl patches in a locked cabinet is a good practice to prevent unauthorized access and to keep them out of reach of children or individuals who should not have access to the medication. However, it is not the most critical safety instruction. Proper application and usage are more important.
Choice B rationale:
While preparing the skin by cleaning with an antiseptic scrub solution is a necessary step when applying a transdermal medication like a fentanyl patch, it is not the most critical safety instruction. It is a standard part of the application process but does not address the overarching safety concerns related to fentanyl use.
Choice D rationale:
Using fentanyl patches as needed for breakthrough pain without clear guidance from a healthcare provider is not a safe practice. Fentanyl is a potent medication with a high risk of overdose, and its use should always be closely monitored and directed by a healthcare professional. Self-adjusting the dosage without medical supervision can lead to serious safety issues.
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