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

c) Assessing pain management response.
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 atached 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.
a) Coﬀee ground secretions drainage via nasogastric tube.
This is not the correct answer because it is not a priority action that the PN should do for a postoperative patient with a PCA machine. Coﬀee ground secretions are dark brown or black granular material that are drained from the stomach via a nasogastric tube. They indicate bleeding in the upper gastrointestinal tract, such as from an ulcer, gastritis, or esophageal varices. Coﬀee ground secretions are a serious sign that require immediate atention and treatment³. However, they are not directly related to the use of a PCA machine or postoperative pain management. The PN should monitor the nasogastric tube drainage of the postoperative patient and report any coﬀee ground secretions to the health care provider, but this is not a priority action for a patient with a PCA machine.
b) Nasogastric tube suctioning.
This is not the correct answer because it is not a priority action that the PN should do for a postoperative patient with a PCA machine. Nasogastric tube suctioning is a procedure that involves applying negative pressure to a nasogastric tube to remove gastric contents from the stomach. It can be used to decompress the stomach, prevent vomiting or aspiration, or treat gastrointestinal bleeding or obstruction⁴. However, it is not directly related to the use of a PCA machine or postoperative pain management. The PN should perform nasogastric tube suctioning as ordered by the health care provider and according to protocol, but this is not a priority action for a patient with a PCA machine.

d) Ineﬀective pain management report.
This is not the correct answer because it is not an action that the PN should do for a postoperative patient with a PCA machine. Ineﬀective pain management report is an outcome or evaluation that indicates that the patient's pain is not adequately controlled or relieved by the current treatment plan. It may be caused by various factors, such as inadequate dosing, inappropriate medication choice, poor adherence, tolerance, or side eﬀects⁵. However, it is not an action that the PN can implement or perform for a postoperative patient with a PCA machine. The PN should assess and document the patient's pain management response and report any ineﬀective pain management to the health care provider, but this is not an action for a patient with a PCA machine.

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Correct Answer is B

Explanation

The correct answer is choiceb. Chest pain and dysrhythmia.

Choice A rationale:

Decreasing gastrointestinal (GI) cramping and nausea are not typical adverse effects of vasopressin.In fact, vasopressin can cause abdominal cramps and nausea as side effects.

Choice B rationale:

Chest pain and dysrhythmia are significant adverse effects of vasopressin.Vasopressin can cause vasoconstriction, leading to myocardial ischemia and arrhythmias.

Choice C rationale:

Vasodilation of the extremities is not an adverse effect of vasopressin.Instead, vasopressin typically causes vasoconstriction, which can lead to peripheral ischemia.

Choice D rationale:

Hypotension and tachycardia are not common adverse effects of vasopressin.Vasopressin is more likely to cause hypertension due to its vasoconstrictive properties.

A. Reduce the client's interaction with others during the day. B. Use distraction and therapeutic communication skills. C. Awaken the client earlier for daily morning care. D. Clarify reality with the client about delusional thoughts.

Correct Answer is B

Explanation

Choice A rationale:

Reducing the client's interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and worsen the client's agitation and delusions. It does not address the client's emotional distress.

Choice B rationale:

Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client's focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.

Choice C rationale:

Awakening the client earlier for daily morning care may further disrupt the client's sleep patterns and worsen agitation. It does not address the underlying issue of delusional thoughts and the client's emotional distress.

Choice D rationale:

Clarifying reality with the client about delusional thoughts can be counterproductive in dementia care. The client's cognitive impairment may make it challenging for them to understand or accept the clarification, leading to increased frustration and agitation. It is essential to use a more empathetic and therapeutic approach.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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