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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Montelukast does not improve peripheral vasodilation. It is a leukotriene receptor antagonist used to reduce inflammation in the airways.
Choice B rationale:
Montelukast does not increase the WBC count. It works by reducing inflammation in the airways, not by affecting the immune system.
Choice C rationale:
Montelukast does not neutralize gastric acid. It is not an antacid or proton pump inhibitor, it is used to reduce inflammation in the airways.
Choice D rationale:
Montelukast reduces bronchial inflammation. It helps to prevent asthma attacks and exercise-induced bronchoconstriction by reducing inflammation in the airways.
Correct Answer is D
Explanation
Choice A rationale:
AST (Aspartate Aminotransferase) is a liver enzyme and its levels are used to assess liver function, not the effectiveness of epoetin alfa.
Choice B rationale:
Troponin is a cardiac marker used to diagnose heart attacks. It has no relation with the effectiveness of epoetin alfa.
Choice C rationale:
T4 (Thyroxine) is a thyroid hormone. Its levels indicate thyroid function, not the effectiveness of epoetin alfa.
Choice D rationale:
Hgb (Hemoglobin) levels are used to assess the effectiveness of epoetin alfa. Epoetin alfa is a medication that stimulates the production of red blood cells, thereby increasing hemoglobin levels in the blood. Normal hemoglobin levels are 13.5 to 17.5 g/dL in men and 12.0 to 15.5 g/dL in women.
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