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 D
Explanation
A thready pulse refers to a pulse that is weak and difficult to palpate. It may disappear or weaken with light pressure. This can be an indication of decreased peripheral perfusion or reduced blood volume. By documenting the finding as "Thready pulse volume," the nurse is accurately describing the quality of the pulse and its response to light pressure.
Incorrect:
A. Missing pulse: A missing pulse would mean that the pulse is not palpable at all, even without applying pressure.
B. Light pressure applied to pulse: This is not a description of the pulse quality, but rather a description of the action taken to assess the pulse.
C. Pulse skips beats: This would mean that the pulse is irregular, with beats being missed or added. In this case, the pulse disappears when light pressure is applied and returns when the pressure is removed, which describes a thready pulse volume.
Correct Answer is B
Explanation
Choice A: Document the client's loss of memory in the record.
While it's important to document changes in a patient's condition, this should not be the first action. The confusion might be temporary and due to the new environment. It's crucial to first address the patient's immediate needs.
Choice B: Remind the client what day of the week it is.
This is the best action to take. The patient is likely experiencing "relocation stress syndrome," which can cause confusion and disorientation in a new environment. Reminding her of the day can help reorient her and alleviate her confusion.
Choice C: Encourage the client to rest during the day.
While rest is important, it doesn't directly address the patient's confusion about the day of the week. Furthermore, excessive daytime sleep can disrupt the patient's sleep-wake cycle and potentially exacerbate confusion.
Choice D: Notify the family of the change in the client's condition.
While it's important to keep the family informed, this should not be the first action. The nurse should first address the patient's confusion and monitor her to see if the confusion persists or improves.
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