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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Glucose Dextrose Oral (GDO) is not typically used in the immediate management of anaphylactic shock. Anaphylaxis requires rapid treatment to address severe allergic reactions and GDO does not play a role in this emergency situation.
Choice B reason: Epinephrine (Adrenaline) is the first-line treatment for anaphylactic shock. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, reverse hives, and reduce swelling of the face, lips, and throat.
Choice C reason: Dexamethasone (Decadron) is a corticosteroid that may be used in the treatment of anaphylaxis to reduce inflammation. However, it is not the first medication administered due to its slower onset of action compared to epinephrine.
Choice D reason: 0.9% Normal Saline is used for intravenous fluid resuscitation in anaphylactic shock but is secondary to the administration of epinephrine. It helps to maintain blood pressure and is important in the overall management but not the first medication given.
Correct Answer is B
Explanation
Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.
Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.
Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.
Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.
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