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: Renal dysfunction is common in older adults and can lead to decreased clearance of medications from the body, increasing the risk of toxicity. Monitoring for signs of toxicity is crucial in this population.

B: Pancreatic impairment can affect digestion and insulin production but is not the primary reason for monitoring medication toxicity in older adults.

C: Increased gastric motility is not typically associated with aging. In fact, decreased gastric motility is more common and can affect drug absorption.

D: Increased blood volume is not a common physiological change in older adults. Decreased renal function and changes in body composition are more relevant factors affecting medication metabolism and excretion.

A. Petechiae B. Blood pressure C. Nausea D. Cyanosis

Correct Answer is C

Explanation

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

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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 A

Explanation

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Correct Answer is C

Explanation

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