A nurse is caring for a client who is postoperative and using a PCA pump. For which of the following actions should the nurse intervene?

The client administers a PCA dose as soon as their pain returns.

The client is ambulating with the PCA pump.

The client administers a PCA dose prior to dressing changes.

The client requests their partner administer PCA doses while they sleep.

Answer and Explanation

The Correct Answer is D

A. The client administers a PCA dose as soon as their pain returns: This is an appropriate action because PCA pumps are designed for the client to self-administer medication when pain begins to recur, maintaining adequate control and preventing severe discomfort.

B. The client is ambulating with the PCA pump: Ambulation with the PCA pump is acceptable as long as the pump is securely attached to an IV pole or portable stand and safety measures are followed. Mobility helps prevent postoperative complications such as deep vein thrombosis.

C. The client administers a PCA dose prior to dressing changes: Administering a dose before a painful procedure helps achieve optimal pain control, ensuring the client is comfortable during care activities.

D. The client requests their partner administer PCA doses while they sleep: The nurse should intervene because only the client should activate the PCA pump. Allowing another person to administer doses increases the risk of oversedation and respiratory depression, making this practice unsafe.

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Correct Answer is A

Explanation

A. Administers the injection in the abdomen: Enoxaparin should be injected subcutaneously into the abdomen at least 2 inches away from the umbilicus. The abdominal area provides consistent absorption and reduces the risk of bruising or tissue injury.

B. Massages the site to enhance absorption: The site should not be massaged after injection, as this can cause bruising, tissue irritation, and increased bleeding due to the anticoagulant effect of enoxaparin.

C. Releases the skin fold before injecting the medication: The skin fold should be maintained throughout the injection to ensure that the medication is delivered into the subcutaneous tissue, not the muscle.

D. Aspirates the medication after injection: Aspiration should be avoided because it can cause tissue trauma and bruising. Enoxaparin should be administered smoothly without pulling back on the plunger.

A. Change the IV tubing every 24 hours. B. Monitor the client's weight weekly. C. Change the IV dressing every 96 hours. D. Perform blood glucose monitoring hourly.

Correct Answer is A

Explanation

A. Change the IV tubing every 24 hours: TPN solutions are rich in glucose and amino acids, creating an excellent medium for bacterial growth. Changing the IV tubing every 24 hours minimizes the risk of infection and sepsis associated with central line use.

B. Monitor the client's weight weekly: Clients receiving TPN require close monitoring of fluid status and nutritional response. Weight should be checked daily, not weekly, to promptly identify fluid imbalances or overfeeding.

C. Change the IV dressing every 96 hours: Central line dressings used for TPN should be changed every 48–72 hours (if gauze) or every 7 days (if transparent and intact), unless soiled or loose. Changing every 96 hours exceeds safe practice guidelines.

D. Perform blood glucose monitoring hourly: Hourly glucose checks are unnecessary unless the client is critically ill or experiencing unstable blood glucose levels. Typically, glucose is monitored every 4–6 hours to detect hyperglycemia related to TPN.

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A nurse is caring for a client who is postoperative and using a PCA pump. For which of the following actions should the nurse intervene?

Nursing Test Bank

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