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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client's statements suggest significant distress, feelings of being a burden, and a sense of hopelessness related to their obsessive-compulsive disorder (OCD). Given the severity of these statements, it is crucial for the PN to assess the client's risk of suicide or self-harm. Asking directly about suicidal thoughts or considering suicide as an option allows the PN to evaluate the immediate safety of the client and take appropriate actions to ensure their well-being.
While the other options may also provide relevant information, they are not as critical as assessing the client's risk of suicide.
B. Questioning about which rituals are most often used to reduce anxiety can help gather information about the client's specific OCD symptoms and coping mechanisms.
C. Determining what makes the client think people are laughing can provide insight into their perception of how others view them, but it may not address the immediate risk of harm.
D. Asking about the impact of obsessions and compulsions on sleep can help assess the client's overall functioning, but it does not address the immediate risk of suicide.
Correct Answer is ["A","B","D"]
Explanation
The practical nurse (PN) should include the following actions when assessing a client for signs and symptoms of fluid volume excess:
- Palpate the rate and volume of the pulse: Fluid volume excess can lead to an increased pulse rate and bounding pulse due to the increased blood volume.
- Measure body weight at the same time daily: Monitoring daily weights can help identify fluid retention or weight gain, which can be indicative of fluid volume excess.
- Observe the color and amount of urine: Changes in urine color and output can provide information about kidney function and fluid balance. In fluid volume excess, urine output may be increased and urine may appear pale or diluted.
The following options are incorrect:
- Check fingernails for the presence of clubbing: Clubbing of the fingernails is not directly related to fluid volume excess. It is a finding commonly associated with chronic respiratory conditions and certain cardiac disorders.
- Compare muscle strength of both arms: Assessing muscle strength is not directly related to fluid volume excess. It is more relevant when evaluating neurological or musculoskeletal conditions.
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