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 A rationale:

Consulting a pharmaceutical sales representative is not the best option. While they are knowledgeable about the medications they promote, their primary role is to market their company’s products, and they may not have comprehensive information about other medications.

Choice B rationale:

While a nursing team member can be a valuable resource, they may not have the specific knowledge about the medication in question. It’s also important to remember that medication information can change frequently, and relying on another person’s knowledge may lead to errors.

Choice C rationale:

The client’s family can provide useful information about how the client has been taking the medication at home, but they are unlikely to have detailed pharmacological knowledge about the medication.

Choice D rationale:

A nursing drug guide is a reliable and up-to-date resource that provides comprehensive information about medications, including indications, contraindications, dosages, potential side effects, and interactions. Therefore, when unfamiliar with a medication, the nurse should consult a nursing drug guide.

A. Docusate sodium. B. Pseudoephedrine. C. Omeprazole. D. Guaifenesin.

Correct Answer is B

Explanation

Choice A rationale:

Docusate sodium is a stool softener and does not have a direct effect on blood pressure. It is generally safe for individuals with hypertension.

Choice B rationale:

Pseudoephedrine is a decongestant that can raise blood pressure or interfere with the effectiveness of some prescribed blood pressure medications. Therefore, it is contraindicated for clients with hypertension.

Choice C rationale:

Omeprazole is a proton pump inhibitor used to decrease stomach acid. It does not have a significant impact on blood pressure and is generally safe for individuals with hypertension.

Choice D rationale:

Guaifenesin is an expectorant used to thin mucus in the air passages. It does not have a significant impact on blood pressure and is generally safe for individuals with hypertension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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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?