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 C
Explanation
Choice A rationale:
Donepezil does not decrease urinary output. It works by increasing the amount of a certain naturally occurring substance in the brain.
Choice B rationale:
Donepezil does not improve pulmonary function. Its primary function is to improve mental function.
Choice C rationale:
Donepezil improves cognitive function. It can improve thinking ability and slow the loss of these abilities in people who have Alzheimer’s disease.
Choice D rationale:
Donepezil does not decrease the incidence of seizures. In fact, patients should inform their healthcare provider if they have a history of seizures before starting donepezil.
Correct Answer is C
Explanation
Choice A rationale:
Dry mouth is a common side effect of diphenhydramine. Diphenhydramine is an antihistamine that is often used to treat allergies, insomnia, and symptoms of the common cold. It works by blocking the effects of histamine, a substance in the body that causes allergy symptoms. One of the effects of histamine is increased salivation, so when diphenhydramine blocks this effect, it can lead to dry mouth.
Choice B rationale:
Nausea is also a common side effect of diphenhydramine. This can occur because diphenhydramine can slow down the emptying of the stomach, leading to feelings of nausea. Additionally, diphenhydramine can affect the vestibular system in the inner ear, which can also lead to feelings of nausea.
Choice C rationale:
Agitation is considered an idiosyncratic reaction to diphenhydramine. An idiosyncratic reaction is an unusual or unexpected reaction to a drug that is not related to the usual pharmacological action of the drug. While diphenhydramine is typically used for its sedative effects, in some cases it can cause paradoxical central nervous system stimulation, leading to agitation.
Choice D rationale:
Dizziness is another common side effect of diphenhydramine. This occurs because diphenhydramine can affect the vestibular system in the inner ear, which plays a key role in maintaining balance. When this system is affected, it can lead to feelings of dizziness.
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