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 C

Explanation

A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.

B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.

C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.

D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.

A. 20 mg B. 0.20 mg C. 0.2 mg D. 2.0 mg

Correct Answer is C

Explanation

A: 20 mg is incorrect and represents a significant overdose. It is not an appropriate transcription for two tenths of a milligram.

B: 0.20 mg is not the best practice because it can be misread as 20 mg if the decimal point is missed. Leading zeros should be used without trailing zeros to prevent errors.

C: 0.2 mg is the correct transcription. It clearly represents two tenths of a milligram and minimizes the risk of misinterpretation.

D: 2.0 mg is incorrect and represents a tenfold overdose. It is not an appropriate transcription for two tenths of a milligram.

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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 C

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Explanation

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