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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client to bring all medications, supplements, and herbs currently being taken to the next clinic appointment (Choice A) is the best course of action. This allows the healthcare provider to review the client's entire medication regimen, identify any potential interactions or duplications, and make appropriate adjustments. It promotes medication safety and ensures that the client receives the most effective and safe treatment.
Choice B rationale:
Using a medication reminder system (Choice B) is a helpful suggestion but does not address the issue of potential duplications or interactions between medications. While a reminder system can improve adherence, it does not provide a comprehensive solution to the problem of multiple prescriptions for the same indication.
Choice C rationale:
Making certain a family member knows the name and use of all medications currently being taken (Choice C) is a useful practice for medication safety but may not be sufficient to address the issue of multiple prescriptions. Relying solely on a family member's knowledge may lead to misunderstandings or omissions in the medication regimen.
Choice D rationale:
Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider (Choice D) is a relevant piece of advice for medication safety. However, it does not directly address the issue of multiple prescriptions for the same indication. It is essential for the client to have a complete and accurate record of all medications, both prescribed and over-the-counter, to ensure safe and effective treatment.
Correct Answer is C
Explanation
The correct answer is c. Recommend using a breast shield.
Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.
Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.
Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.
Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.