Which action should the practical nurse (PNA) prioritize for postoperative patient with a PCA (Patient- Controlled Analgesia) machine?
Coffee ground secretions drainage via nasogastric tube.
Nasogastric tube suctioning.
Assessing pain management response.
Ineffective pain management report:
The Correct Answer is C
This is the correct answer because it is the most important and relevant action that the PN should do for a postoperative patient with a PCA machine. A PCA machine is a computerized device that allows the patient to self-administer a preset dose of pain medication, usually an opioid, by pressing a buton. The PCA machine is attached to an intravenous (IV) line that delivers the medication directly into the bloodstream. The PCA machine can provide effective and individualized pain relief for postoperative patients, as well as increase their sense of control and satisfaction¹².
The PN should assess the pain management response of the postoperative patient with a PCA machine by monitoring their pain level, vital signs, oxygen saturation, sedation level, and side effects. The PN should use a valid and reliable pain scale, such as the numeric rating scale (NRS) or the visual analog scale (VAS), to measure the patient's pain intensity and relief. The PN should also check the settings and functioning of the PCA machine, such as the dose, lockout interval, and limit. The PN should document and report the patient's pain management response and any problems or complications with the PCA machine to the health care provider.
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Related Questions
Correct Answer is C
Explanation
The action that the practical nurse (PN) should take in this situation is to complete an advance directive form and place it in the client's medical record. Advance directives are legal documents that outline an individual's healthcare preferences and treatment decisions in the event that they become unable to communicate or make decisions for themselves. By completing an advance directive, the client's wishes regarding life-saving measures can be documented and honored.
A. Placing a "Do Not Resuscitate" sign outside the client's door and at the bedside is not sufficient documentation of the client's wishes. While it may serve as a visual reminder to healthcare providers, it is important to have the client's preferences clearly documented in their medical records through a formal advance directive.
B. Reassuring the client that life-saving measures will not be taken without consent is important for establishing trust and communication. However, it is essential to have the client's preferences formally documented to ensure that their wishes are respected and followed.
D. Notifying the client's healthcare provider of the client's wishes is an important step, but it should be done after completing the advance directive form. The advance directive will provide clear instructions to the healthcare team regarding the client's preferences, and the healthcare provider can review and acknowledge these wishes accordingly.
Correct Answer is B
Explanation
Bathing a bedfast client with the bed in a high position poses a potential risk to the client's safety. Lowering the bed to a safe height is important to prevent falls and injuries during the bathing procedure. The PN should promptly intervene and instruct the UAP to lower the bed to an appropriate level before continuing with the bathing process.
A. While remaining in the room to supervise the UAP is important, it should be done after ensuring the client's safety by lowering the bed. If the bed is not lowered, the risk of injury remains, and the PN should take immediate action to address the safety concern.
C. Determining if the UAP would like assistance is a valid consideration, but it should be secondary to addressing the safety issue of the bed height. Once the bed is lowered, the PN can assess if additional assistance is required and provide support accordingly.
D. Assuming care of the client immediately may be necessary if the client is in immediate danger or experiencing an urgent medical situation. However, in this case, the primary concern is addressing the safety issue related to the bed height, and the PN can address this by instructing the UAP to lower the bed.
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