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 D
Explanation
A. Holding one's breath when rising from a sitting position can lead to increased intra-abdominal pressure and is not a recommended practice.
B. While changing positions regularly is important for preventing complications of immobility, relying solely on a partner every 4 hours may not provide enough frequent movement.
C. Antiembolic stockings are typically worn to prevent blood clots during periods of immobility and should not be removed while in bed unless instructed by a healthcare provider.
D. Performing ankle and knee exercises every hour helps maintain joint mobility and circulation, reducing the adverse effects of immobility.
Correct Answer is B
Explanation
A. Moving items away from the client can prevent injury during the seizure, but it is not the first action to take.
B. If a client begins to experience a seizure, the first action the nurse should take is to help them lie on the floor safely to prevent injury from falling.
C. Turning the client onto their side helps maintain a clear airway and prevents aspiration during the seizure but should only be done after helping the client to lie in the floor.
D. Loosening the client's clothing is important for ensuring adequate ventilation but is not the first priority during a seizure.
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