A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following actions should the nurse take?

Encourage family members to press the PCA button for the client.

Monitor the client's respiratory status every 4 hours.

Teach the client how to self-medicate using the PCA device.

Administer an oral opioid for breakthrough pain.

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging family members to press the PCA button for the client is not recommended. The PCA device is designed to be used by the patient to manage their own pain. Allowing someone other than the patient to administer the medication can lead to over-sedation or respiratory depression. The patient must have control over the PCA device to ensure that they are receiving the medication based on their pain level and not someone else's perception of their pain.

Choice B reason: Monitoring the client's respiratory status every 4 hours is important but may not be sufficient for a patient receiving morphine via a PCA device. According to clinical guidelines, respiratory rate, sedation, and pain scores must be recorded more frequently after the initiation of PCA therapy—typically every 15 minutes for the first hour, then every 30 minutes for the next 2 hours, and hourly until 24 hours post-operation. This is to ensure early detection of any adverse effects such as respiratory depression, which is a risk with opioid administration.

Choice C reason: Teaching the client how to self-medicate using the PCA device is the correct action. Patient education is crucial for the effective use of PCA. The patient should be instructed on how to use the device, including when to press the button and the importance of only the patient controlling the button. This empowers the patient to manage their pain effectively and safely, ensuring that they receive the medication when needed and reducing the risk of over-sedation or under-medication.

Choice D reason: Administering an oral opioid for breakthrough pain may be necessary if the PCA does not adequately control the patient's pain. However, this should be done cautiously and typically under the guidance of a pain management team or physician. Breakthrough pain medication is usually reserved for instances where the PCA is not providing sufficient pain relief, and the patient's pain is assessed to be higher than what can be managed by the PCA alone.

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Correct Answer is A

Explanation

Choice A reason : A severe, throbbing headache is a common and significant manifestation of autonomic dysreflexia. This condition is a potentially life-threatening medical emergency that can occur in individuals with spinal cord injuries, typically above the T6 level. The headache results from a sudden and severe increase in blood pressure due to an exaggerated response of the autonomic nervous system to a stimulus below the level of the injury.

Choice B reason: Hypotension, or low blood pressure, is not a manifestation of autonomic dysreflexia. In fact, the condition is characterized by hypertension, or high blood pressure, which is a critical sign that requires immediate attention to prevent complications such as stroke or seizure.

Choice C reason: Fever is not a direct manifestation of autonomic dysreflexia. While a fever may indicate an infection or other systemic issue, autonomic dysreflexia itself is specifically associated with a rapid onset of high blood pressure and other autonomic disturbances.

Choice D reason: Cyanosis of the head and neck, which refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is not a typical manifestation of autonomic dysreflexia. The condition primarily causes hypertension and its associated symptoms, rather than issues with oxygenation.

A. Administer prednisone before the test. B. Consult with the provider to change to a CT scan. C. Assess the alkaline phosphatase level. D. Obtain the client's allergy history to seafood.

Correct Answer is A

Explanation

Choice A reason: Administering prednisone before the test may be part of a premedication protocol for clients with a history of allergic reactions to contrast media. However, this is typically done for iodinated contrast used in CT scans, not for gadolinium-based contrast agents used in MRA.

Choice B reason: Consulting with the provider to change to a CT scan would not be appropriate if the client is allergic to iodinated contrast dye, as CT scans commonly use iodinated contrast. MRA typically uses gadolinium-based contrast agents, which may be safer for clients with iodine allergies.

Choice C reason: Assessing the alkaline phosphatase level is not directly related to preparing a client with a contrast dye allergy for an MRA. Alkaline phosphatase is an enzyme measured in blood tests and is not specific to contrast media allergies.

Choice D reason: Obtaining the client's allergy history to seafood is not necessary for MRA preparation. While there is a common misconception that seafood allergies are related to iodinated contrast allergies, the evidence does not support this association.

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A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations?

Correct Answer is A

Explanation

A nurse is preparing a client for a magnetic resonance angiography (MRA). The client is allergic to iodinated contrast dye. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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