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 D
Explanation
A: The statement “Benefit may outweigh the risk” is more applicable to Pregnancy Risk Category D or X drugs, where there is evidence of risk but potential benefits may justify use in certain situations.
B: Studies showing fetal risk are associated with Pregnancy Risk Category D or X drugs. Category A drugs have not shown fetal risk in controlled studies.
C: Drugs that are contraindicated in pregnant women fall under Pregnancy Risk Category X, where the risks clearly outweigh any potential benefits.
D: Fetal harm is unlikely for Pregnancy Risk Category A drugs. These drugs have been tested in controlled studies and have not shown any risk to the fetus, making them safe for use during pregnancy.
Correct Answer is C
Explanation
A: Requesting the risk manager to obtain consent for HIV testing from the client is important but should not be the first action. Immediate steps to reduce the risk of infection are more urgent.
B: Completing an incident report is necessary for documentation and follow-up but is not the immediate priority following a needle stick injury.
C: Washing the site of injury with soap and water is the first and most immediate action. This helps to reduce the risk of infection by removing any potential contaminants from the wound.
D: Consenting to post-exposure treatment with antiretroviral medications is important if there is a risk of HIV exposure. However, this should follow the initial step of cleaning the wound.
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