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 C
Explanation
The client finding that necessitates immediate attention by the practical nurse (PN) is a client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. Bright red rectal bleeding can indicate active bleeding and immediate intervention is required to assess the severity of the bleeding, control the bleeding if possible, and prevent further complications.
A. The older client with a blood pressure of 100/70 after receiving meperidine for pain may require further assessment, but it does not indicate an immediate life-threatening condition.
B. Pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy may be expected due to the surgical procedure, but it should still be monitored.
D. Brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis is also an expected finding.
Correct Answer is B
Explanation
This statement suggests that the client has found sources of emotional support and is relying on them to cope with the challenges posed by his prognosis. Acceptance of a prognosis often involves coming to terms with the reality of the situation and finding ways to manage the emotional and practical aspects of it. By acknowledging the support he has received from his faith and family, the client demonstrates a willingness to lean on these resources for strength and comfort.
The other statements do not necessarily reflect acceptance of the prognosis:
A. "I think I had this disease for a long time, but the doctor did not find it." This statement implies a sense of disbelief or frustration with the delay in diagnosing the disease, rather than acceptance of the prognosis itself.
C. "I understand this is a disease that occurs mostly in older men." While this statement shows some awareness of the disease, it does not necessarily indicate acceptance. It may simply reflect an understanding of the demographics of prostate cancer without addressing the client's personal feelings or coping mechanisms.
D. "I do not have any use for those who say this disease is going to win." This statement may indicate resistance or defiance towards the negative outlook associated with the disease. It suggests a desire to maintain a positive attitude but does not necessarily reflect a full acceptance of the prognosis and its implications.
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