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:
Sleeping with the window open for fresh air may not be the best solution in this scenario. While fresh air can be beneficial for sleep, it might not effectively block out the noise from the freeway and the nearby apartment complex. Furthermore, depending on the climate and location, having the window open might lead to discomfort or temperature-related issues.
Choice B rationale:
Performing exercise at bedtime is not a recommended solution for someone experiencing difficulty sleeping due to external noise. Exercise before bedtime can increase alertness and make it even more challenging to fall asleep, especially if it's vigorous exercise. It may exacerbate the problem rather than alleviate it.
Choice C rationale:
Having a couple of drinks at bedtime is not a suitable solution for sleep problems. Alcohol can disrupt sleep patterns and lead to poor-quality sleep. It may help the patient fall asleep initially but can lead to frequent awakenings and a less restful night's sleep.
Choice D rationale:
The correct choice is to wear soft earplugs for sleep. Soft earplugs can effectively reduce or block out external noise, providing a quieter sleep environment. This is a practical and safe solution to address the noise issue in the patient's apartment complex. It promotes better sleep quality without any negative side effects.
Correct Answer is B
Explanation
Choice A rationale:
Placing electrodes on all four extremities is not the initial step in using a Transcutaneous Electrical Nerve Stimulator (TENS) unit. It may not be necessary for the specific pain management needs of the patient and can be uncomfortable or impractical.
Choice B rationale:
This is the correct initial step when starting TENS treatment. The nurse should adjust the settings to a level below the threshold at which the patient feels a tingling sensation. This ensures that the treatment is comfortable and safe for the patient. The goal is to provide pain relief, not to induce discomfort.
Choice C rationale:
Turning the unit on before attaching it to the patient is not advisable. It's essential to connect the electrodes to the patient first and then turn on the TENS unit. This sequence helps prevent accidental electrical stimulation before the device is properly set up.
Choice D rationale:
Applying conductive jelly to uncoated electrodes is a step in preparing the electrodes for use, but it should be done after attaching the electrodes to the patient's skin. This choice does not address the initial step in TENS treatment, which is setting the stimulation level. .
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