• 4 ounce apple Juice 8 ounces milk
• 4 ounces broth
• 4 ounces tea

A client remains on strict intake and output (1&O) on the first postoperative day and documents the last 8 hours of intake on the I&O bedside record above. How many mL should the practical nurse (PN) document in the client's electronic medical record (EMR)?

(Enter numeric value only.)

This is the correct answer because it is the most important and relevant action that the PN should do for a postoperative patient with a PCA machine. A PCA machine is a computerized device that allows the patient to self-administer a preset dose of pain medication, usually an opioid, by pressing a buton. The PCA machine is attached to an intravenous (IV) line that delivers the medication directly into the bloodstream. The PCA machine can provide effective and individualized pain relief for postoperative patients, as well as increase their sense of control and satisfaction¹².

The PN should assess the pain management response of the postoperative patient with a PCA machine by monitoring their pain level, vital signs, oxygen saturation, sedation level, and side effects. The PN should use a valid and reliable pain scale, such as the numeric rating scale (NRS) or the visual analog scale (VAS), to measure the patient's pain intensity and relief. The PN should also check the settings and functioning of the PCA machine, such as the dose, lockout interval, and limit. The PN should document and report the patient's pain management response and any problems or complications with the PCA machine to the health care provider.

A. Checking the medical record for the correct signed consent form prior to the examination is the primary responsibility of the practical nurse (PN). Ensuring that the consent form is properly signed and documented in the medical record is crucial for legal and ethical reasons before proceeding with any invasive procedure.
B. While explaining the examination is important, obtaining informed consent is the responsibility of the provider, not the PN. The PN can clarify information but should not be the one to explain the procedure in detail and obtain the signature.
C. Explaining the procedure to a family member and obtaining their signature is not appropriate, as consent must come from the client unless they are incapacitated. Family members cannot give consent for procedures unless legally designated as such.
D. While asking if the client understands the exam and the need for the consent form is a good practice for ensuring informed consent, the PN's responsibility focuses more on verifying that the consent has been properly obtained and documented.