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.

Answer and Explanation

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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Correct Answer is A

Explanation

A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.

B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.

C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.

D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.

A. Place the client supine with knees bent. B. Raise the head of the client’s bed 15 to 20 degrees. C. Assess the client for manifestations of shock. D. Cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation.

Correct Answer is D

Explanation

A: Placing the client supine with knees bent can help reduce strain on the abdominal area but is not the immediate first action.

B: Raising the head of the client’s bed 15 to 20 degrees is not the priority action in this situation.

C: Assessing the client for manifestations of shock is important but should follow the immediate action of protecting the eviscerated wound.

D: Covering the area with a sterile dressing moistened with 0.9% sodium chloride irrigation is the correct first action. This helps protect the exposed organs and tissues from contamination and keeps them moist until surgical intervention can be performed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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