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 B
Explanation
The correct answer is B. Responsibility.
Choice A rationale:
“Fairness.” Fairness involves treating all clients equally and without bias. While fairness is an important aspect of professionalism, it is not specifically demonstrated by evaluating the effectiveness of pain medication.
Choice B rationale:
“Responsibility.” Responsibility refers to the nurse’s duty to provide safe and effective care. By checking the client to evaluate the effectiveness of pain medication, the nurse is fulfilling their responsibility to monitor the client’s response to treatment and ensure their comfort and well-being.
Choice C rationale:
“Confidence.” Confidence involves the nurse’s self-assurance in their skills and knowledge. While confidence is important in nursing practice, it is not the primary component demonstrated in this scenario.
Choice D rationale:
“Advocacy.” Advocacy involves supporting and speaking up for the client’s needs and preferences. Although advocacy is a crucial part of nursing, the act of evaluating pain medication effectiveness is more directly related to the nurse’s responsibility to provide appropriate care.
By demonstrating responsibility, the nurse ensures that the client’s pain management is effective and that any necessary adjustments to the treatment plan are made.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale:
Culture can influence a person's perception and expression of pain. It's important to consider cultural factors when assessing and managing pain because beliefs and attitudes about pain can vary significantly among different cultural groups. This can affect how pain is experienced and communicated.
Choice B rationale:
Psychological factors, such as anxiety, depression, and coping mechanisms, play a significant role in the experience of pain. Assessing psychological factors is essential for a comprehensive understanding of the patient's pain experience and developing appropriate pain management strategies.
Choice C rationale:
Understanding the patient's history of pain is crucial for a focused pain assessment. Previous experiences with pain, including the cause, intensity, and effectiveness of previous pain management strategies, can provide valuable insights into the current pain situation.
Choice D rationale:
Assessing contributing factors, such as concurrent medical conditions, injuries, or environmental factors, is essential to determine the underlying causes of pain and develop an effective pain management plan.
Choice E rationale:
Verbal indicators are essential for assessing pain. Patients often describe their pain in words, and understanding their descriptions and expressions of pain is fundamental to evaluating its intensity, location, quality, and duration.
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