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:

Renal excretion time slows for medication. As people age, kidney function gradually decreases, which slows the excretion of medications. This can lead to increased levels of the drug in the body, which can increase the risk of side effects.

Choice B rationale:

Hepatic enzymes do not process medications more rapidly in older adults. In fact, liver function also decreases with age, which can slow the metabolism of medications.

Choice C rationale:

Brain receptors do not become less sensitive to medications in older adults. The sensitivity of brain receptors to medications can vary widely and is not necessarily related to age.

Choice D rationale:

Gastric emptying rate does not increase with age. On the contrary, it often slows down, which can affect the absorption of some medications.

A. Check blood pressure with the client standing. B. Administer a 0.9% sodium chloride IV bolus. C. Place the client in a supine position. D. Measure blood pressure with the client sitting.

Correct Answer is C

Explanation

Choice A rationale:

Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.

Choice B rationale:

Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.

Choice C rationale:

Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.

Choice D rationale:

Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.

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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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Naxlex Comprehensive Predictor Exams

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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?