A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management.
The nurse enters the room to find the client asleep and his partner pressing the button to dispense a dose of analgesia.
Which of the following responses should the nurse make?
"Your husband should decide when more medication is needed.”.
"Why do you think your husband needs more medication when he is asleep?".
"It's a good idea to help make sure your husband can sleep comfortably.”.
"Next time you think he needs more medication, call me and I'll push the button.”.
The Correct Answer is B
The correct answer is choice B. "Why do you think your husband needs more medication when he is asleep?"
Choice A rationale:
"Your husband should decide when more medication is needed.” This response is incorrect because it implies that the partner has the authority to decide when the client needs pain medication, which violates the purpose of a PCA pump. A PCA pump is specifically designed for client-controlled pain management, ensuring that the patient, not anyone else, controls when they receive pain medication. Allowing someone else to press the button can lead to overmedication and safety risks.
Choice B rationale:
"Why do you think your husband needs more medication when he is asleep?" This response is correct because it prompts the partner to reflect on their actions and provides an opportunity for the nurse to educate about the proper use of PCA pumps. It addresses the immediate issue without being confrontational and opens the door for further discussion on the importance of client safety and correct PCA use.
Choice C rationale:
"It's a good idea to help make sure your husband can sleep comfortably.” This response is incorrect as it endorses inappropriate and unsafe behavior. It encourages the partner to continue pressing the PCA button, risking the client's safety due to potential overmedication, which can lead to severe complications, such as respiratory depression.
Choice D rationale:
"Next time you think he needs more medication, call me and I'll push the button.” This response is incorrect because it contradicts PCA protocols and removes the control from the client. The nurse is responsible for monitoring the client’s pain and safety, not administering medication upon another person’s request. This approach also increases the risk of dosing errors and undermines the purpose of patient-controlled analgesia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Patient-controlled analgesia (PCA) is a method of pain management that allows the patient to administer their own pain medication within specified limits, but it doesn't reduce the workload of the nurse. The nurse is responsible for setting up and monitoring the PCA pump, educating the patient, assessing their pain, and ensuring safety. Therefore, this choice is incorrect.
Choice B rationale:
PCA does not completely eliminate pain. It provides the patient with control over their pain relief by allowing them to self-administer medication within preset limits. However, it does not guarantee the complete absence of pain. Pain relief is provided within a safe dosage range, but some level of pain may still be experienced. Therefore, this choice is incorrect.
Choice C rationale:
PCA does not eliminate the risk of adverse drug effects entirely. The nurse must monitor the patient for signs of adverse effects, such as respiratory depression or sedation. While the patient has control over medication administration, there are still risks associated with opioid analgesics. Therefore, this choice is incorrect.
Choice D rationale:
The principal advantage of using patient-controlled analgesia (PCA) is that it reduces patient anxiety about pain by giving the patient more control over its management. This choice is correct because PCA empowers the patient to self-administer pain medication when needed, which can lead to better pain control and reduced anxiety. The nurse sets safe dosage limits and monitors the patient, ensuring safety while providing a sense of control.
Correct Answer is C
Explanation
Choice A rationale:
Keeping bright lights on in the room is not conducive to relaxation. Bright lights can be stimulating and may increase stress, which is counterproductive when trying to manage pain through relaxation techniques.
Choice B rationale:
Using relaxation techniques as a way to wake up in the morning is not the intended purpose of these techniques. Relaxation techniques are typically used to reduce stress, anxiety, and pain, especially when one is trying to rest or sleep.
Choice C rationale:
Tensing and relaxing individual muscle groups, starting with the toes and feet, is a common method for progressive muscle relaxation. This technique can help reduce muscle tension and promote overall relaxation. It is an effective approach to pain management.
Choice D rationale:
Trying to tense and relax all of the muscles of the body at the same time may be difficult for most individuals and is not a commonly recommended relaxation technique. It can be challenging to achieve the level of focus and control required for this method, and it may not be as effective as focusing on individual muscle groups.
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