A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?
"You should push the button before physical activity to allow maximum pain control.”
"Continuous PCA infusion is designed to allow fluctuating plasma medication levels."
"You can adjust the amount of pain medication you receive by pushing on the keypad."
"The PCA will deliver a double dose of medication when you push the button twice."
The Correct Answer is A
A. "You should push the button before physical activity to allow maximum pain control.": Preemptively using the PCA before activities such as ambulation or physical therapy helps prevent breakthrough pain, allowing the client to perform activities more comfortably. This approach maximizes the effectiveness of pain control.
B. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels.": Continuous PCA is designed to maintain consistent plasma levels of medication, not fluctuating levels. This ensures steady pain control rather than peaks and troughs.
C. "You can adjust the amount of pain medication you receive by pushing on the keypad.": Clients cannot override the preset dosage limits on a PCA pump. The device is programmed by the healthcare provider to deliver safe doses, so self-adjusting the amount is not permitted.
D. "The PCA will deliver a double dose of medication when you push the button twice.": PCA pumps have lockout intervals to prevent overdosing. Pressing the button multiple times during the lockout period will not deliver extra doses, so this statement is incorrect and could be dangerous if misunderstood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Severe hypertension: Cushing’s triad is characterized by increased systolic blood pressure with widening pulse pressure as a compensatory response to maintain cerebral perfusion during increased intracranial pressure. Severe hypertension is a hallmark finding.
B. Narrowed pulse pressure: In Cushing’s triad, the pulse pressure is typically widened, not narrowed, due to elevated systolic pressure and relatively lower diastolic pressure. Narrowed pulse pressure does not reflect the classic pattern associated with increased ICP.
C. Diastolic murmur: A diastolic murmur is a cardiac finding unrelated to increased intracranial pressure and is not a component of Cushing’s triad. It does not provide information about cerebral perfusion or ICP.
D. Increased heart rate: Cushing’s triad involves bradycardia rather than tachycardia, as part of the body’s compensatory response to elevated ICP. An increased heart rate is inconsistent with this classic presentation.
Correct Answer is B
Explanation
A. Apply sterile gloves: Standard precautions are followed when handling feeding equipment, but sterile gloves are not required for routine administration of intermittent gastric feedings. Clean gloves are sufficient to prevent contamination.
B. Assess gastric residual volume: Checking gastric residual volume before feeding helps evaluate the client’s tolerance of the previous feeding and reduces the risk of aspiration. High residual volumes may indicate delayed gastric emptying and the need to hold or adjust the feeding.
C. Flush the tube with 60 mL of sodium chloride: Flushing the tube is important before and after feedings to maintain patency, but the amount and timing depend on institutional protocol. It is performed after assessing residual volume rather than as the first step.
D. Chill the formula: Feeding formulas should generally be at room temperature to prevent gastrointestinal discomfort and cramping. Chilling the formula is not recommended prior to administration.
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