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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Related Questions
Correct Answer is C
Explanation
A: A trochanter roll is used to prevent external rotation of the hips, not to prevent plantar flexion contractures.
B: A sheepskin heel pad provides cushioning and helps prevent pressure ulcers on the heels but does not prevent plantar flexion contractures.
C: A footboard is used to prevent plantar flexion contractures by keeping the feet in a neutral position. This helps maintain proper alignment and prevents the muscles and tendons from shortening.
D: An abduction pillow is used to maintain hip abduction, typically after hip surgery, and does not prevent plantar flexion contractures.
Correct Answer is D
Explanation
A: Using a microwave for cooking is generally safe for older adults with decreased vision. Microwaves are user-friendly and reduce the risk of burns or fires compared to stovetops. However, it is important to ensure that the microwave is at an accessible height and that the user can read the controls or has them memorized.
B: Handrails in the bathroom are a safety feature, not a risk. They provide support and stability, reducing the likelihood of falls, which is crucial for individuals with decreased vision. Properly installed handrails can significantly enhance bathroom safety.
C: Electrical cords placed along the walls are typically not a safety risk if they are secured properly and do not create tripping hazards. It is important to ensure that cords are not loose or crossing walkways where they could cause falls.
D: Scatter rugs in the kitchen are a significant safety risk for older adults with decreased vision. These rugs can easily cause tripping and falling, especially if they are not secured with non-slip backing. Removing scatter rugs or securing them properly is essential to prevent accidents.
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