A nurse is reinforcing teaching with a client about using a PCA for postoperative pain management.
Which of the following statements should the nurse make?
"A large dose of pain medication is administered with each injection.”.
"You will have control of administering your own pain medication.”.
"Your partner can push the PCA button for you if you are asleep.”.
"The pain medication is delivered into your muscle.”.
The Correct Answer is B
Choice A rationale:
This statement is not accurate and may confuse the client. In a Patient-Controlled Analgesia (PCA) system, a predetermined dose is delivered when the patient activates the device. The dose is usually controlled to prevent excessive medication administration.
Choice B rationale:
This statement is correct. The essence of PCA is that the patient has control over administering their pain medication within set limits or time intervals. The patient can self-administer doses when needed, ensuring effective pain management.
Choice C rationale:
Allowing the partner to push the PCA button for the patient is not recommended. PCA systems are designed to be controlled by the patient themselves to prevent potential overdosing. Involving someone else in the administration can lead to safety concerns.
Choice D rationale:
PCA systems do not deliver medication into the muscle. They typically deliver medication intravenously (IV) or subcutaneously. This statement is inaccurate and could lead to misconceptions about how the PCA system works.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Bradycardia, a slow heart rate, is not typically associated with acute pain. In response to pain, the body usually experiences increased heart rate (tachycardia) as part of the stress response.
Choice B rationale:
A decreased respiratory rate is not an expected finding in response to acute pain. Acute pain often leads to increased respiratory rate as the body attempts to manage the pain and stress.
Choice C rationale:
Hypoglycemia, a low blood sugar level, is not a typical physiological response to acute pain. Acute pain is more likely to induce a release of stress hormones, such as cortisol and adrenaline, which can lead to increased blood sugar levels.
Choice D rationale:
Hypertension, or elevated blood pressure, is an expected physiological response to acute pain. Pain activates the body's stress response, leading to increased sympathetic nervous system activity, which can cause vasoconstriction and increased blood pressure. This response helps prepare the body to cope with the pain and stress. Monitoring blood pressure in a client reporting acute pain is essential to assess the impact of pain and determine appropriate pain management strategies.
Correct Answer is C
Explanation
Choice C rationale:
The most crucial instruction regarding the safety of fentanyl patches is to apply them as directed by the primary care provider. Fentanyl is a potent opioid medication, and its misuse or improper application can lead to serious health risks, including overdose. Therefore, following the prescriber's instructions is of utmost importance to ensure the patient's safety.
Choice A rationale:
Storing fentanyl patches in a locked cabinet is a good practice to prevent unauthorized access and to keep them out of reach of children or individuals who should not have access to the medication. However, it is not the most critical safety instruction. Proper application and usage are more important.
Choice B rationale:
While preparing the skin by cleaning with an antiseptic scrub solution is a necessary step when applying a transdermal medication like a fentanyl patch, it is not the most critical safety instruction. It is a standard part of the application process but does not address the overarching safety concerns related to fentanyl use.
Choice D rationale:
Using fentanyl patches as needed for breakthrough pain without clear guidance from a healthcare provider is not a safe practice. Fentanyl is a potent medication with a high risk of overdose, and its use should always be closely monitored and directed by a healthcare professional. Self-adjusting the dosage without medical supervision can lead to serious safety issues.
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