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 B

Explanation

A. The nurse should not open the outermost flap of the sterile kit toward the body as it increases the risk of contaminating the sterile field with microorganisms from the nurse's clothing or body.
B. Holding bottles of sterile solution with the label in the palm of the hand prevents drips from contaminating the nurse's gloves or sterile field, as drips can follow along the label and onto the hand or field.
C. Liquids should be poured into containers within the sterile field to maintain sterility.
D. The sterile field should be placed at or above waist level to maintain sterility and prevent contamination by non-sterile surfaces.

A. Flex the client's knees. B. Roll the client as one unit in a smooth, continuous motion. C. Place the client on the side of the bed nearest the direction they will be turned. D. Place the client's arms at their sides.

Correct Answer is B

Explanation

A. Flex the client's knees:
While knee flexion can reduce back strain in some situations (e.g., when lying supine), it is not recommended during repositioning for a back injury as it may cause unnecessary spinal movement.

B. Roll the client as one unit in a smooth, continuous motion:
Logrolling maintains spinal alignment and reduces stress or twisting of the spine, which is crucial for clients with back injuries or spinal conditions.

C. Place the client on the side of the bed nearest the direction they will be turned:
The client should be positioned centrally on the bed to prevent falls and ensure adequate space for a safe, controlled logroll.

D. Place the client's arms at their sides:
The client’s arms should typically be crossed over their chest to prevent them from becoming trapped or causing unnecessary spinal movement during the roll.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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