A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device.
Which of the following actions by the nurse requires intervention by the charge nurse?

The nurse asks the client to demonstrate dose delivery.

The nurse administers a PCA dose for the client.

The nurse reassures the client that the PCA device will not cause an overdose.

The nurse monitors the client for oversedation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.

Choice B rationale:

The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.

Choice C rationale:

Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.

Choice D rationale:

Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.

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Correct Answer is A

Explanation

Choice A rationale:

Levalbuterol is a short-acting beta agonist, which is commonly used for quick relief in an acute asthma attack.

Choice B rationale:

Cromolyn is used as a preventive treatment for asthma, not for treating an acute attack.

Choice C rationale:

Budesonide is a corticosteroid used for long-term control and prevention of symptoms, not for immediate relief during an acute asthma attack.

Choice D rationale:

Ipratropium is used as a bronchodilator for asthma, but it’s typically not the first choice for treating an acute asthma attack.

A. Increased temperature. B. Decreased blood pressure. C. Increased respiratory rate. D. Report of decreased pain.

Correct Answer is C

Explanation

Choice A rationale:

Increased temperature is not a direct indication of naloxone’s effectiveness. Naloxone works by reversing the effects of opioids, which do not typically include fever.

Choice B rationale:

While naloxone can cause an abrupt withdrawal in opioid-dependent individuals, leading to symptoms such as hypertension, it does not typically decrease blood pressure in opioid overdose cases.

Choice C rationale:

Naloxone works by reversing the life-threatening depression of the central nervous system and respiratory system caused by an opioid overdose. Therefore, an increased respiratory rate after administration would indicate that the medication is effective.

Choice D rationale:

Naloxone reverses the effects of opioids, including pain relief. Therefore, a report of decreased pain would not indicate that the medication is effective.

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A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device.Which of the following actions by the nurse requires intervention by the charge nurse?

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A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device.
Which of the following actions by the nurse requires intervention by the charge nurse?