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.
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Related Questions
Correct Answer is C
Explanation
A. Use an 18-gauge, 1-inch needle to administer the medication: An 18-gauge needle is too large for subcutaneous injections. Heparin is usually administered with a smaller gauge needle, such as 25-27 gauge, and a length of 1/2 to 5/8 inch.
B. Massage the injection site after withdrawing the needle: Massage is not recommended for heparin injections because it may increase the risk of bruising and bleeding at the site.
C. Heparin is administered subcutaneously (SQ), typically in the abdomen at least 2 inches away from the umbilicus to avoid areas with scar tissue or bruising, which can affect absorption.
D. The air bubble should not be expelled when using a prefilled syringe. It helps ensure full dose delivery and prevents medication from tracking into the skin, reducing bruising.
Correct Answer is D
Explanation
A. Percussion between the iliac crest and ribs at the midaxillary line is not typically used to assess for flank tenderness related to pyelonephritis.
B. Pushing fingers upward into the two lowest intercostal spaces is not a standard method for assessing flank tenderness and may not accurately assess the kidneys.
C. Palpating along both sides of the lumbar vertebral column may not specifically target the area of the kidneys and may not accurately assess flank tenderness.
D. Striking a flat hand covering the costovertebral angle (CVA) elicits pain or tenderness in individuals with pyelonephritis due to inflammation of the kidneys. This maneuver is a classic method for assessing flank tenderness associated with renal pathology.
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