A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?
Inform the provider that the PCA is not providing adequate pain relief.
Ask the provider for a prescription to decrease the continuous rate.
Instruct the client to push the button more frequently.
Instruct the client's caregiver to push the PCA button when the client is resting.
The Correct Answer is B
A. Informing the provider that the PCA is not providing adequate pain relief is not accurate in this scenario because the client rates their pain as 2, indicating that they are experiencing minimal discomfort.
B. Asking the provider for a prescription to decrease the continuous rate is appropriate since the client has not needed to deliver any bolus doses for over 2 hours, suggesting that the current continuous rate may be higher than necessary for their pain level. Adjusting the PCA settings can help to prevent potential over-medication and side effects while maintaining adequate pain control.
C. Instructing the client to push the button more frequently is unnecessary as the client is already reporting low pain levels and has not expressed a need for additional medication.
D. Allowing the caregiver to push the PCA button when the client is resting is not recommended because PCA systems are designed for patient-controlled analgesia, ensuring that the patient manages their own pain without risking over-medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.
B. This is the safest method to prevent accidental dislodgement of the tracheostomy tube. By securing the new ties first, the tracheostomy tube remains in place, reducing the risk of complications.
C. A secure knot that can be released quickly in case of emergency is recommended.
D. Extending the client's neck during tie securing can cause discomfort and respiratory compromise. The client's neck should be in a neutral position.
Correct Answer is D
Explanation
A. While reading the medication label is important, doing it twice prior to administration may not be necessary and could consume additional time.
B. Using one patient identifier is a standard practice for medication administration, but it may not specifically address ensuring the safety of administering a medication for the first time.
C. While it's important to assess the client's history of medication use, asking if they have taken a similar medication may not provide sufficient information about the specific medication being administered.
D. Accessing the online drug formulary for an unfamiliar medication helps the nurse verify the medication's indications, contraindications, dosage, and administration considerations, ensuring safe administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.