12. A nurse is assisting in the care of a client who is scheduled for surgery. Nurses Notes
Exhibits

A nurse is reinforcing preoperative teaching about pain management using a patient-controlled analgesia (PCA) system with a client. Which of the following three statements should the nurse include?

“Push the button as the PCA prior to your pain level becoming severe so you can remain comfortable.”

“Your family member should push the PCA button for you while you are sleeping.”

“You we still have to request pain medication from the nurse from time to time.”

“There is minimal risk of an overdose of pain medication while using the PCA pump.”

"Using the PCA regularly will provide a constant level of pain relief."

Answer and Explanation

Correct Answer : A,D,E

A.   This is correct because it is important for clients to manage their pain proactively by using the PCA before the pain becomes intense. This helps maintain a consistent level of comfort and prevents the pain from escalating to a difficult-to-control level.
B.   This is incorrect and potentially dangerous. Only the client should press the PCA button, as they are the best judge of their own pain. Allowing someone else to do so can lead to overmedication.
C.   This is incorrect because the purpose of the PCA is to give the client control over their pain management. While additional medication may be needed in some cases, the PCA is typically sufficient for managing postoperative pain.
D.   This is correct because PCA devices are designed with safety mechanisms that prevent overdose. The pump is programmed to deliver a controlled amount of medication within a specified time frame, ensuring that the client cannot administer too much medication.
E.   This is correct because consistent use of the PCA can help maintain steady pain control. The system allows the client to self-administer pain relief as needed, helping to manage pain effectively without large fluctuations.

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Correct Answer is B

Explanation

A. The incentive spirometer should typically be used more frequently, often every 1-2 hours while awake, rather than every 4 hours.

B. Inhaling deeply and holding the breath for a few seconds (often 5-10) is a common recommendation for effective use of the incentive spirometer to maximize lung expansion.

C. The client should be in a sitting position or at a 45-degree angle for optimal use, not just 30 degrees.

D. The recommended breath hold time is usually around 5-10 seconds, not 7 seconds, depending on the specific guidelines provided by the healthcare team.

A. Background B. Recommendation C. Situation D. Assessment

Correct Answer is A

Explanation

A. The Background section of the SBAR communication tool is where relevant medical history, including a family history of malignant hyperthermia, should be included. This information is critical for the surgical team to be aware of before administering anesthesia.

B. The Recommendation section is for suggesting specific actions or interventions based on the current situation and background.

C. The Situation section describes the immediate issue or reason for the handoff, not past medical history.

D. The Assessment section includes the nurse's evaluation of the client’s current condition, not family history.

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12. A nurse is assisting in the care of a client who is scheduled for surgery. Nurses Notes Exhibits A nurse is reinforcing preoperative teaching about pain management using a patient-controlled analgesia (PCA) system with a client. Which of the following three statements should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is reviewing the client's medical record and notices a family history of malignant hyperthermia. In which of the following sections of the SBAR communication tool should the nurse include this information when completing handoff to the surgical team?

Correct Answer is A

Explanation

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12. A nurse is assisting in the care of a client who is scheduled for surgery. Nurses Notes
Exhibits

A nurse is reinforcing preoperative teaching about pain management using a patient-controlled analgesia (PCA) system with a client. Which of the following three statements should the nurse include?