Which assessment is most important to determine if a patient is receiving sufficient sleep?

Choice A reason: This is incorrect. The PCA will not give additional pain medication whenever the button is pushed. The PCA is programmed to deliver a specific dose of pain medication at a specific interval. If the button is pushed before the interval is over, the PCA will not release any medication. This is to prevent overdose and side effects.

Choice B reason: This is incorrect. The PCA will not deliver medication through the IV until the pain is all gone. The PCA is designed to provide pain relief, not pain elimination. The PCA has a limit on how much medication it can deliver in a certain period of time. The patient may still have some pain even after using the PCA.

Choice C reason: This is correct. You or a designated family member are the only one who gets to push the PCA button-nobody else may do so. The PCA is intended to give the patient control over their pain management. The patient should push the button when they feel pain, not when someone else thinks they need it. Allowing others to push the button can lead to under- or over-medication, which can be harmful.

Choice D reason: This is incorrect. Wait until the pain becomes severe before pushing the PCA button is not a good instruction. The PCA is more effective when the patient pushes the button before the pain becomes too intense. Waiting too long can make the pain harder to control and require more medication. The patient should use the PCA as needed to keep the pain at a tolerable level..

Choice A reason: This is an incorrect choice because calling the operator to activate the fire alarm is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Calling the operator to activate the fire alarm is an important action to alert the fire department and the other staff and patients, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before calling for help.

Choice B reason: This is an incorrect choice because closing the door to contain the fire is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Closing the door to contain the fire is a helpful action to prevent the fire from spreading to other areas, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before containing the fire.

Choice C reason: This is an incorrect choice because utilizing a fire extinguisher to put out the fire is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Utilizing a fire extinguisher to put out the fire is a possible action to control the fire, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before attempting to extinguish the fire.

Choice D reason: This is the correct choice because removing the patient to a safe area is the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Removing the patient to a safe area is the most urgent and priority action to protect the patient from the fire, smoke, and heat. The nurse should first assess the patient for any injuries or burns, and then move the patient to a safe and clear location away from the fire.