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 A

Explanation

Choice A rationale:

History of vomiting at home for 3 days prior to surgery. Rationale: This information is relevant to the client's surgical history and may impact their current condition. It is essential to inform the receiving nurse about this history to ensure appropriate postoperative care.

Choice B rationale:

Soft abdomen, absent bowel sounds, no bleeding on dressing. Rationale: While this information is important for assessing the client's postoperative status, it is less urgent than the history of vomiting. The abdominal assessment suggests normal findings after surgery.

Choice C rationale:

Declining to take ice chips for complaints of dry mouth. Rationale: While this information indicates the client's complaint of dry mouth, it is not as critical as the history of vomiting or the assessment of surgical outcomes.

Choice D rationale:

Peripheral pulses present with full range of motion of both legs. Rationale: This information is important but primarily related to the client's vascular and neurological status. It may not be as immediately relevant as the history of vomiting in the context of a recent surgery.

A. Report the finding to the healthcare provider. B. Document the purposeful response to pain. C. Initiate seizure precautions immediately. D. Administer a prescribed PRN analgesic.

Correct Answer is A

Explanation

The correct answer is **a. Report the finding to the healthcare provider.**

Choice A rationale:

The nurse should report the finding of the client's response to a painful stimulus to the healthcare provider. This response, known as a decorticate posturing, is an abnormal motor response that indicates a severe brain injury or dysfunction. It is a sign of impaired consciousness and requires immediate medical attention and intervention.

Choice B rationale:

While documenting the client's response to pain is important, the primary action the nurse should take is to report the finding to the healthcare provider. Decorticate posturing is a neurological emergency that requires prompt medical evaluation and treatment.

Choice C rationale:

Initiating seizure precautions is not the appropriate action in this case. Decorticate posturing is not a seizure, but rather an abnormal motor response indicating a severe brain injury or dysfunction. Seizure precautions would not be the appropriate intervention.

Choice D rationale:

Administering a prescribed PRN analgesic is not the appropriate action in this case. Decorticate posturing is a neurological emergency that requires immediate medical attention, not just pain management. Administering an analgesic would not address the underlying neurological issue.

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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

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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