A nurse caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?
Check the display on the PCA pump.
Obtain an order for another pain medication for breakthrough pain.
Administer a bolus of medication.
Encourage the client to administer a demand dose.
The Correct Answer is A
A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.
B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.
C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.
D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Degenerative joint changes can affect mobility and overall health but do not directly contribute to aspiration pneumonia.
B: Decreased gastric secretions can affect digestion but are not a primary factor in the development of aspiration pneumonia.
C: A decreased sense of smell can affect appetite and food intake but does not directly lead to aspiration pneumonia.
D: A diminished cough reflex is a significant age-related change that can contribute to the development of aspiration pneumonia. The cough reflex helps clear the airway of food, liquid, and other foreign materials. When this reflex is diminished, the risk of aspiration and subsequent pneumonia increases.
Correct Answer is A
Explanation
A: Cleaning hearing aids with alcohol wipes is not recommended as it can damage the devices. The client should use a soft, dry cloth or a cleaning tool designed for hearing aids.
B: Expecting the hearing aids to whistle when cupping a hand over them is normal. This feedback occurs due to the sound being reflected back into the microphone.
C: Not using hairspray while wearing hearing aids is correct. Hairspray can clog the microphone and other components of the hearing aids.
D: Changing the batteries once a week is a reasonable practice, depending on the usage and type of hearing aids. This statement does not indicate a need for further instruction.
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