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 A
Explanation
The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by: The correct answer is choice A: supporting surface and internal tissues.
Choice A rationale:
An abdominal binder is primarily used to support surface and internal tissues. It provides gentle compression and support to the abdominal area, which can reduce pain and discomfort. By holding the incision site together and supporting the surrounding tissues, it can minimize movement and strain on the incision, helping to alleviate pain.
Choice B rationale:
While an abdominal binder may indirectly contribute to back support by stabilizing the abdominal area, its primary purpose is to support the surgical site. Enhancing early ambulation is more related to patient mobility and not the primary purpose of the binder.
Choice C rationale:
Abdominal binders do not increase warmth to the incision site. In fact, excessive warmth can lead to sweating and moisture, potentially increasing the risk of infection. The primary purpose is to provide support.
Choice D rationale:
An abdominal binder does not keep sutures and staples in place. The sutures and staples are used to secure the incision, and the binder is placed over them to provide support and compression. However, the binder itself is not responsible for keeping sutures and staples in place. .
Correct Answer is B
Explanation
Choice A rationale:
Offering an ice pack to place on the neck would not be an appropriate response in this situation. The patient has already complained that the ice massage is making the pain worse, so providing additional cold application may exacerbate their discomfort.
Choice B rationale:
The most helpful response in this scenario is to acknowledge the patient's discomfort and stop the cold application. Not everyone responds positively to cold therapy, and it's essential to respect the patient's feedback and provide alternative methods for pain relief.
Choice C rationale:
Alternating hot and cold applications may be helpful for some patients, but in this case, the patient has already expressed that the ice massage is exacerbating their pain. Suggesting this approach without addressing the patient's immediate concern is not appropriate.
Choice D rationale:
While it's true that the discomfort from the ice massage may subside in a few minutes, it's important to prioritize the patient's comfort and address their pain immediately. Continuing an intervention that is causing increased pain is not in the patient's best interest.
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