A nurse caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?
Check the display on the PCA pump.
Obtain an order for another pain medication for breakthrough pain.
Administer a bolus of medication.
Encourage the client to administer a demand dose.
The Correct Answer is A
A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.
B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.
C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.
D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: A simple face mask provides a moderate concentration of oxygen but does not have a one-way valve to deliver the highest concentration of oxygen.
B: A Venturi mask delivers a precise concentration of oxygen but is not designed to provide the highest concentration of oxygen with a one-way valve.
C: A non-rebreather mask is the correct choice. It has a one-way valve that prevents exhaled air from re-entering the bag, allowing the delivery of the highest concentration of oxygen to the client.
D: A partial rebreather mask provides a high concentration of oxygen but does not have a one-way valve, making it less effective than a non-rebreather mask for delivering the highest oxygen concentration.
Correct Answer is B
Explanation
A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.
B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.
C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.
D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.
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