A nurse is providing teaching to a client who is about to begin using a PCA pump to deliver morphine for postoperative pain management. Which of the following statements by the client indicates an understanding of the teaching?
"The lockout interval prevents me from receiving too much medication."
"Each time I push the button, I receive the same amount as a morphine injection."
"My family can push the button for me on a regular basis."
"It will take about 30 minutes to feel relief after I push the button."
The Correct Answer is A
A. "The lockout interval prevents me from receiving too much medication.": The lockout interval on a PCA pump ensures that the client cannot administer more medication than is safe within a set period, preventing overdose or over-sedation.
B. "Each time I push the button, I receive the same amount as a morphine injection.": The PCA pump delivers a smaller, controlled dose of morphine each time the button is pressed, rather than the same dose as a traditional injection.
C. "My family can push the button for me on a regular basis.": The client should be the only one pressing the PCA button to prevent overdose and ensure safe administration. Family members should not push the button for the client.
D. "It will take about 30 minutes to feel relief after I push the button.": PCA delivers pain medication on demand, and the client may feel relief within a few minutes, not 30 minutes. Pain relief can be quicker depending on the medication’s action and how it’s delivered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer digoxin by IV bolus: Digoxin slows conduction through the AV node and can worsen a complete heart block. It is contraindicated in this condition and may lead to further bradycardia or cardiac arrest.
B. Prepare the client for temporary pacing:Third-degree (complete) heart block results in electrical dissociation between atria and ventricles, leading to dangerously low heart rates and inadequate perfusion. The definitive treatment is temporary pacing to stabilize the cardiac rhythm until permanent pacing can be arranged.
C. Instruct the client to perform the Valsalva maneuver: This maneuver is used to terminate supraventricular tachycardias by stimulating the vagus nerve. It is not indicated in bradyarrhythmias like third-degree heart block and could further lower the heart rate.
D. Perform carotid sinus massage: This is another vagal maneuver used to treat tachycardias, not bradycardias. Performing it in a client with third-degree heart block could dangerously reduce the heart rate further and is therefore inappropriate.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Instruct the client to rise slowly from a sitting position: The client is showing signs of orthostatic hypotension, with a drop in blood pressure when changing positions. Providing instructions to rise slowly helps prevent dizziness and potential falls, especially in the presence of anemia-related fatigue and reduced oxygen delivery.
- Evaluate a stool sample for occult blood: The client has anemia (Hgb 8 g/dL, Hct 24%) and is taking naproxen, a nonsteroidal anti-inflammatory drug (NSAID) known to cause gastrointestinal bleeding. Occult GI blood loss is a common cause of iron deficiency anemia in such clients. Identifying hidden bleeding is a priority to determine the cause of anemia.
Rationale for Incorrect Choices:
- Draw a blood sample for arterial blood gases: There is no evidence of acute respiratory distress or hypoxemia requiring blood gas analysis. The client’s oxygen saturation is 94% on room air, and breath sounds are clear, making this action unnecessary at this time.
- Perform a 12-lead ECG: Although the client has tachycardia (HR 108/min), this is likely a compensatory response to anemia. Without chest pain or other signs of cardiac compromise, a 12-lead ECG is not the most immediate action.
- Administer an inhaled bronchodilator: The client reports dyspnea with exertion, but there is no indication of bronchospasm or wheezing. Breath sounds are clear bilaterally, so a bronchodilator is not indicated and would not address the underlying issue of anemia.
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