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 ["B","C","D","E"]
Explanation
A. Prepare for chest tube placement: Chest tube placement is indicated for conditions like pneumothorax or pleural effusion, which are not clearly present in this scenario. Immediate interventions should focus on stabilizing the client and evaluating cardiopulmonary status first.
B. Ensure that the client has venous access: Establishing IV access is essential for rapid administration of medications, fluids, or emergency interventions if the client’s condition deteriorates. This is a priority in acute postoperative complications.
C. Place the client in High Fowler's position: Elevating the head of the bed improves lung expansion, reduces dyspnea, and enhances oxygenation in a client experiencing sudden respiratory distress and crackles, which may indicate pulmonary edema or fluid overload.
D. Activate the rapid response team: The client exhibits acute respiratory distress, hypoxemia, tachypnea, and cardiovascular changes. Activating the rapid response team ensures timely advanced intervention and evaluation to prevent further deterioration.
E. Administer fondaparinux as prescribed: Postoperative clients following total hip arthroplasty are at high risk for venous thromboembolism. Administering anticoagulant therapy, such as fondaparinux, helps prevent pulmonary embolism, which could be causing the client’s sudden dyspnea.
F. Administer midazolam as prescribed: Midazolam is a sedative and would not address the client’s acute respiratory distress. Sedation could worsen hypoxemia and respiratory compromise in this scenario.
Correct Answer is A
Explanation
A. "You should increase your daily fluid intake.": Adequate hydration is important during early pregnancy to support maternal blood volume expansion, amniotic fluid production, and overall health. Increasing fluid intake can also help alleviate common symptoms such as constipation and mild nausea.
B. "Headaches are expected throughout pregnancy.": While mild headaches can occur, persistent or severe headaches are not considered normal and may indicate complications such as hypertension. Clients should be advised to report significant or recurrent headaches to their provider.
C. "You will feel your baby moving within the next month.": Fetal movement, or “quickening,” typically occurs between 16–20 weeks of gestation for primigravid clients, not at 9–10 weeks. Early reassurance should focus on expected developmental milestones for this stage.
D. "Hormone shifts often cause severe vomiting.": Mild nausea and vomiting are common in early pregnancy due to hormonal changes, but severe vomiting (hyperemesis gravidarum) is not expected and requires medical evaluation for hydration and nutritional management.
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