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 B
Explanation
Choice A rationale:
Granulating tissue in a foot ulcer is a positive sign of wound healing, but it may not be directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. The primary goal of pregabalin in this context is to reduce pain and neuropathic symptoms.
Choice B rationale:
A reduced level of pain is the most relevant indicator of the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin is an antiepileptic medication used to manage neuropathic pain. A decrease in pain indicates that the medication is effectively managing the client's symptoms.
Choice C rationale:
Improved visual acuity is not directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin primarily targets neuropathic pain and sensory symptoms, not visual function.
Choice D rationale:
A full volume of pedal pulses is a positive sign of adequate circulation in the lower extremities, but it may not be directly related to the effectiveness of pregabalin in treating neuropathy symptoms. The primary goal of pregabalin in this context is pain management.
Correct Answer is A
Explanation
The correct answer is choice a. Ask the wife to stop and assess the client’s swallowing reflex.
Choice A rationale:
Assessing the client’s swallowing reflex is crucial because facial paralysis and inability to move one side can indicate a risk of aspiration. Ensuring the client can safely swallow before giving any fluids is a priority to prevent complications like aspiration pneumonia.
Choice B rationale:
Giving the wife a straw might seem helpful, but it does not address the underlying risk of aspiration. Without assessing the swallowing reflex, using a straw could still lead to aspiration.
Choice C rationale:
Assisting the wife in giving small sips of water without assessing the swallowing reflex first is unsafe. The client might not be able to swallow properly, increasing the risk of aspiration.
Choice D rationale:
Obtaining thickening powder is a good step for clients with swallowing difficulties, but it should be done after assessing the swallowing reflex. The priority is to first determine if the client can swallow safely.
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