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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Diuretics are used to reduce the fluid overload.

B. Administering oxygen helps alleviate hypoxia and support respiratory function.

C. Epinephrine is not indicated for these symptoms and could exacerbate the situation.
D. Stopping the transfusion is essential if transfusion-related complications are suspected.
E. Placing the client in high-Fowler's position helps optimize respiratory function and reduce fluid overload.

A. When removing the medication from the medication drawer B. At the end of the shift C. When reconciling counts of controlled substances D. When preparing the medication dosage E. Directly before administering the medication

Correct Answer is ["A","D","E"]

Explanation

A. Comparing the medication administration record and the medication label when removing the medication ensures that the correct medication is being obtained.
B. Comparing the medication administration record and the medication label at the end of the shift is not a specific time for medication safety checks. It is essential to verify medications at each step of the medication administration process to prevent errors.
C. While controlled substance counts are important for security and inventory, they do not involve direct medication administration verification for an individual client.

D. Comparing the medication administration record and the medication label when preparing the medication dosage ensures that the correct medication and dose are being administered.
E. Comparing the medication administration record and the medication label directly before administering the medication is the final check to ensure accuracy and prevent medication errors.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins, Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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