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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: The passage of flatus is a clear indication that intestinal function is returning. It shows that the gastrointestinal tract is beginning to move gas through the intestines, which is a positive sign of recovery after abdominal surgery.
B: A request for a cup of tea and some toast indicates that the client is feeling better and has an appetite, but it does not specifically indicate the return of intestinal function.
C: Hypoactive bowel sounds in two quadrants suggest reduced intestinal activity, which is not a sign of returning intestinal function. Normal bowel sounds should be present in all quadrants.
D: Abdominal distention can indicate a buildup of gas or fluid in the intestines, which is not a sign of returning intestinal function. It may suggest an obstruction or other complications.
Correct Answer is A
Explanation
A: Renal dysfunction is common in older adults and can lead to decreased clearance of medications from the body, increasing the risk of toxicity. Monitoring for signs of toxicity is crucial in this population.
B: Pancreatic impairment can affect digestion and insulin production but is not the primary reason for monitoring medication toxicity in older adults.
C: Increased gastric motility is not typically associated with aging. In fact, decreased gastric motility is more common and can affect drug absorption.
D: Increased blood volume is not a common physiological change in older adults. Decreased renal function and changes in body composition are more relevant factors affecting medication metabolism and excretion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.