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

Choice A rationale:

Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.

Choice B rationale:

Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.

Choice C rationale:

Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.

Choice D rationale:

Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.

A. CP is one of the most common permanent physical disabilities in children. B. Brain damage with CP is not progressive but does have a variable course. C. Severe motor dysfunction determines the extent of successful habilitation. D. Continued development of the brain lesion determines the child's outcome.

Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.

Choice D rationale:

Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro

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

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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