A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Choice A reason: Telling the partner to call the nurse to push the button is not appropriate. PCA is designed to allow the client to self-administer pain medication based on their own perception of pain. Only the client should press the button to avoid the risk of over-sedation and respiratory depression.

Choice B reason: Encouraging the partner to press the button while the client is asleep can lead to over-medication and serious complications such as respiratory depression.

Choice C reason: Asking the partner why they think more medication is needed when the client is asleep does not address the underlying issue of inappropriate use of the PCA pump.

Choice D reason: The correct answer is d because the client should be the one to decide when more medication is needed. This ensures that the client receives the appropriate amount of pain relief based on their individual needs and prevents the risk of over-sedation.

Choice A reason: While early CPR is crucial, the AED should be attached as soon as it is available to analyze the heart rhythm and provide a shock if needed. Delaying the use of the AED can reduce the chances of successful resuscitation.

Choice B reason: In adults, the carotid pulse is typically checked, not the brachial pulse. The brachial pulse is more commonly assessed in infants.

Choice C reason: The correct answer is c because providing chest compressions at a rate of 100-120 compressions per minute is the recommended rate for effective CPR. High-quality chest compressions are essential for maintaining circulation during cardiac arrest.

Choice D reason: The recommended ratio of chest compressions to rescue breaths is 30:2, not 50:2. Performing 50 compressions before providing rescue breaths is not aligned with current CPR guidelines.