Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
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 a sickle cell crisis.
B. The client has a respiratory rate of 12 breaths per minute.
This is wrong because a respiratory rate of 12 breaths per minute is normal and does not indicate the effectiveness of the PCA pump.
C. The client has a blood pressure of 140/90 mm Hg.
This 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.
D. The client has a pulse oximetry reading of 95%.
This 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%
This question is an excerpt from Nurse Dive's nursing test bank - More questions on this topics. Take the full exam now
Full Explanation
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%
Similar Questions
A nurse is teaching a client who has cancer pain about the use of oral oxycodone with acetaminophen (Percocet).
Which statement by the client indicates a need for further teaching?
A. “I should drink plenty of fluids and eat high-fiber foods to prevent constipation.”
This is wrong because drinking plenty of fluids and eating high-fiber foods can help prevent constipation, which is a common adverse effect of opioids.
B. “I should avoid driving or operating heavy machinery while taking this medication.”
This is wrong because avoiding driving or operating heavy machinery is a safety precaution for clients taking opioids, as they can cause drowsiness and impaired judgment.
C. “I should take this medication only when I have severe pain that does not respond to other drugs.”
The client should take this medicationregularlyas prescribed to maintain a steady level of analgesia and prevent breakthrough pain. Taking the medication only when the pain is severe can lead to inadequate pain relief and increased side effects.
D. “I should report any signs of an allergic reaction, such as rash, itching, or difficulty breathing.”.
This is wrong because reporting any signs of allergic reaction is an important instruction for clients taking any medication, especially opioids, which can cause severe hypersensitivity reactions.
Full Explanation
The correct answer is choice C. The client should take this medication regularly as prescribed to maintain a steady level of analgesia and prevent breakthrough pain.
Taking the medication only when the pain is severe can lead to inadequate pain relief and increased side effects.
Choice A is wrong because drinking plenty of fluids and eating high-fiber foods can help prevent constipation, which is a common adverse effect of opioids.
Choice B is wrong because avoiding driving or operating heavy machinery is a safety precaution for clients taking opioids, as they can cause drowsiness and impaired judgment.
Choice D is wrong because reporting any signs of allergic reaction is an important instruction for clients taking any medication, especially opioids, which can cause severe hypersensitivity reactions.
A nurse is caring for a patient who is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?
A. Respiratory rate: 10 breaths/min
This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids. Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly. The normal respiratory rate for adults is 12 to 20 breaths/min.
B. Blood pressure: 110/70 mm Hg
This is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg.Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.
C. Heart rate: 72 beats/min
This is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min.Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.
D. Temperature: 37°C.
This is wrong because this is the normal body temperature for humans.Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.
Full Explanation
The correct answer is choice A) Respiratory rate: 10 breaths/min. This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.
Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.
The normal respiratory rate for adults is 12 to 20 breaths/min.
Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg. Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.
Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min. Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.
Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans. Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.
A patient who is addicted to heroin is admitted to the hospital for treatment of an infection. The patient is prescribed methadone (Dolophine) as part of a detoxification program. What is the rationale for using methadone in this patient?
A. Methadone prevents withdrawal symptoms and reduces cravings for heroin.
This is wrong because methadone does not prevent withdrawal symptoms, but rather reduces them.
B. Methadone blocks the euphoric effects of heroin and discourages its use.
Methadone blocks the euphoric effects of heroin and discourages its use.Methadone is a synthetic opioid analgesic that produces a cross-tolerance to other narcotics, thereby preventing the user from feeling the high of heroin.Methadone also reduces the withdrawal symptoms and cravings for heroin.
C. Methadone stimulates opioid receptors and enhances natural pain relief.
This is wrong because methadone does not stimulate opioid receptors, but rather occupies them and blocks their activation by heroin.
D. Methadone reverses the respiratory depression caused by heroin overdose.
This is wrong because methadone does not reverse the respiratory depression caused by heroin overdose, but rather carries a risk of overdose itself.
Full Explanation
The correct answer is choice B. Methadone blocks the euphoric effects of heroin and discourages its use. Methadone is a synthetic opioid analgesic that produces a cross-tolerance to other narcotics, thereby preventing the user from feeling the high of heroin. Methadone also reduces withdrawal symptoms and cravings for heroin.
Choice A is wrong because methadone does not prevent withdrawal symptoms, but rather reduces them.
Choice C is wrong because methadone does not stimulate opioid receptors, but rather occupies them and blocks their activation by heroin.
Choice D is wrong because methadone does not reverse the respiratory depression caused by heroin overdose, but rather carries a risk of overdose itself.