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.

Answer and Explanation

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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Correct Answer is C

Explanation

A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.

B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.

C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.

D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.

A. Passage of flatus B. Request for a cup of tea and some toast C. Hypoactive bowel sounds in two quadrants D. Abdominal distention

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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