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:

Answer and Explanation

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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Correct Answer is A

Explanation

The action the practical nurse (PN) should take in this situation is to administer a prescribed PRN (as needed) dose of analgesic.
Severe burning pain along the right side of the trunk is a common symptom of herpes zoster (shingles). Managing the client's pain is an important aspect of care to provide comfort and promote healing. Administering a prescribed PRN dose of analgesic will help alleviate the client's pain and improve their overall well-being. It is crucial to follow the client's prescribed medication regimen and provide pain relief as needed.
The other options are not the most appropriate actions in this situation:

B. Notifying the nursing supervisor of uncontrolled pain may be necessary if the client's pain persists despite appropriate interventions. However, the first step should be to administer an analgesic to address the immediate pain.
C. Giving the next prescribed dose of antiviral medication is important in the treatment of herpes zoster, but it does not directly address the client's current severe burning pain. Analgesics are specifically designed to alleviate pain symptoms.
D. Obtaining an oxygen tank for home administration is not indicated for the management of pain associated with herpes zoster. Oxygen therapy is typically used for respiratory or circulatory conditions and would not be the appropriate intervention for the client's symptom of severe burning pain.

A. Blowing forcefully into the mouthpiece. B. Exhaling slowly after two seconds. C. Using a tight seal around the mouthpiece. D. Sitting upright during the treatment.

Correct Answer is A

Explanation

The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates blowing forcefully into the mouthpiece. The proper way to use an incentive spirometer is to sit upright, hold the spirometer upright, place your mouth around the mouthpiece, breathe out slowly, and then inhale slowly only through your mouth as deeply as you can. Blowing forcefully into the mouthpiece is not the correct way to use an incentive spirometer.

B. Exhaling slowly after two seconds: This is actually a correct action when using an incentive spirometer. The proper way to use an incentive spirometer is to exhale slowly before inhaling deeply.
C. Using a tight seal around the mouthpiece: This is also a correct action when using an incentive spirometer. It’s important to create a tight seal around the mouthpiece with your lips to ensure that you’re inhaling and exhaling only through your mouth.
D. Sitting upright during the treatment: This is another correct action when using an incentive spirometer. Sitting upright helps you to breathe more deeply and fully, which is the goal of using an incentive spirometer.

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Which action should the practical nurse (PNA) prioritize for postoperative patient with a PCA (Patient- Controlled Analgesia) machine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take?

Correct Answer is A

Explanation

A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action.

Correct Answer is A

Explanation

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