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 D

Explanation

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.

A. "You can take the medication with magnesium hydroxide if needed.” B. "Drink up to one liter of fluid per day while taking this medication.” C. "Make sure to take this medication with orange juice.” D. "Avoid driving until adverse effects of this medication are known.” .

Correct Answer is D

Explanation

Choice A rationale:

Fexofenadine can be taken with or without food, and there are no specific interactions with magnesium hydroxide. However, it’s always important to consult a healthcare provider before combining medications.

Choice B rationale:

While staying hydrated is generally good advice, there’s no specific requirement to drink up to one liter of fluid per day while taking fexofenadine.

Choice C rationale:

Fexofenadine should not be taken with fruit juices such as orange juice because they can decrease the absorption of the medication, making it less effective.

Choice D rationale:

Fexofenadine can cause side effects such as dizziness or drowsiness in some people. Therefore, it’s important to avoid driving or operating heavy machinery until you know how this medication affects you.

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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?