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 ["740"]
Explanation
Step 1: Convert 4 oz juice to mL. 4 oz × 30 mL per oz = 120 mL
Step 2: Convert 6 oz hot tea to mL. 6 oz × 30 mL per oz = 180 mL
Step 3: Ice chips are recorded at half their volume. 100 mL ÷ 2 = 50 mL
Step 4: IV bolus is already in mL. 150 mL
Step 5: Convert 8 oz broth to mL. 8 oz × 30 mL per oz = 240 mL
Step 6: Add all the volumes together. 120 mL + 180 mL + 50 mL + 150 mL + 240 mL = 740 mL
The nurse should record 740 mL of intake on the client’s record.
Correct Answer is C
Explanation
A: Calling the prescribing physician is important, but the immediate action should be to withhold the medication to prevent further elevation of potassium levels.
B: Calling the lab to verify the results can be done, but the immediate action should be to withhold the medication.
C: Omitting the KCL dose and documenting it is the correct action. The client’s potassium level is already elevated, and administering additional potassium could be harmful.
D: Giving the ordered KCL as prescribed is not appropriate because the client’s potassium level is already above the normal range.
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.