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 C
Explanation
Choice A rationale:
It is not advisable to use sedative pills for long periods of time without consulting a primary care provider. Prolonged use of sedatives can lead to dependence and other adverse effects. Therefore, this choice is incorrect.
Choice B rationale:
Using sedative pills for short periods of time without physician approval is not a safe practice. Even nonprescription medications, including over-the-counter sedatives, should be used under the guidance of a healthcare provider. This choice is incorrect.
Choice C rationale:
The best advice for the patient is to use sedative pills for short periods of time, but it is best to check with the primary care provider first. This is the most appropriate choice as it emphasizes short-term use while also promoting communication with a healthcare provider to ensure the medication's safety and effectiveness.
Choice D rationale:
Using sedative pills for long periods of time without primary care provider approval is not recommended. It can lead to potential risks and side effects associated with prolonged sedative use. Therefore, this choice is incorrect.
Correct Answer is A
Explanation
Choice A rationale:
NREM (Non-Rapid Eye Movement) sleep is characterized by slow-wave sleep and is often considered restorative. It is the stage of sleep where the body repairs and regenerates tissues, and it is essential for feeling rested and rejuvenated. NREM sleep consists of three stages, with stages 3 and 4 being the deepest and most restful, also known as slow-wave sleep. These stages are essential for physical recovery.
Choice B rationale:
NREM sleep is not characterized by irregular respirations. Irregular breathing patterns are more commonly associated with certain sleep disorders, such as sleep apnea, rather than NREM sleep itself.
Choice C rationale:
NREM sleep is not characterized by increased heart rate. In fact, during NREM sleep, the body typically experiences a decrease in heart rate and blood pressure. The body's physiological functions tend to slow down during NREM sleep to promote rest and recovery.
Choice D rationale:
NREM sleep is not characterized by daytime activity. In contrast, NREM sleep occurs during the night and is a state of deep rest, during which the body is not engaged in daytime activities. It is essential for physical and mental recovery, especially after a day of activity.
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