The nurse is caring for a client with rib fractures and a pneumothorax who reports a pain score of 8/10. The nurse administered prescribed hydromorphone IV push and reassesses the client in 30 minutes. What data indicates that the treatment is effective?
Pain rating of 3 on a scale of 0 to 10 by the client.
Decreased client anxiety.
Respiratory rate of 16 breaths/minute.
PaO2 of 82 mm Hg.
The Correct Answer is A
A. The primary goal of administering hydromorphone IV is to relieve severe pain. A decrease in the pain score from 8/10 to 3/10 indicates that the analgesic intervention has been effective, allowing improved comfort and potentially better respiratory effort.
B. While reduced anxiety may occur as a secondary effect of pain relief, it is not a direct measure of the effectiveness of the opioid analgesic. Anxiety reduction alone does not confirm pain control.
C. Although maintaining a normal respiratory rate is important, opioids can depress respirations. The rate of 16 may reflect adequate breathing, but it does not directly measure pain relief. The client could still be in pain despite a normal respiratory rate.
D. Improvement in oxygenation may occur as a result of better ventilation after pain control, but it is an indirect indicator. PaO2 can be influenced by factors other than pain, such as the pneumothorax or underlying lung injury, so it does not confirm analgesic effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Amyloidosiscan affect the lungs or heart and may contribute to respiratory failure, but this is generally considered a pulmonary or systemic diseasecausing intrapulmonary problems rather than an extrapulmonary cause of ventilatory failure.
B. Pneumothoraxis a pulmonary causeof respiratory failure. It directly impairs lung expansion and gas exchange by causing air to accumulate in the pleural space.
C. Pulmonary edemais another pulmonary causeof respiratory failure. It occurs due to fluid accumulation in the alveoli, impairing oxygenation and ventilation.
D. Opioid analgesic overdoseis an extrapulmonary cause of ventilatory failure. Opioids depress the central nervous system, particularly the medullary respiratory centers, leading to hypoventilation, decreased tidal volume, and elevated arterial CO₂ (hypercapnia). This is a classic example of ventilatory failure caused by a neurologic or pharmacologic extrapulmonary issue, rather than intrinsic lung disease.
Correct Answer is D
Explanation
A. The Rapid Shallow Breathing Index (RSBI) is calculated as the ratio of respiratory rate to tidal volume (in liters). An RSBI <105 is generally considered favorable for weaning. A value of 85 indicates the patient is breathing efficientlyand may be ready to wean.
B. Negative inspiratory force measures inspiratory muscle strength. Values more negative than -20 to -30 cm H2O are considered adequate. A NIF of -28 cm H2O indicates sufficient inspiratory strengthfor spontaneous breathing.
C. A tidal volume ≥5 mL/kg is generally acceptable for weaning. A value of 6 mL/kg indicates adequate ventilationduring spontaneous breathing trials.
D. A FiO2 >40% to maintain adequate oxygen saturation indicates ongoing oxygenation impairment, suggesting the client may not yet be ready for weaning. Successful weaning usually requires an FiO2 ≤40% and PEEP ≤5 cm H2O to maintain SpO2 ≥90–92%, ensuring the lungs can sustain oxygenation without excessive support.
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