A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 5 on a scale from 0 to 10. Which of the following actions should the nurse take first?
Obtain an order for another pain medication for breakthrough pain.
Check the display on the PCA pump.
Administer a bolus of medication.
Encourage the client to administer a demand dose.
The Correct Answer is B
Rationale:
A. While additional medication may be needed, the nurse must first assess the PCA pump to ensure it is functioning properly.
B. The priority action is to assess the PCA pump settings and usage. The display will show how often the patient has attempted doses, how many were delivered, and whether the pump is functioning correctly. This helps determine the cause of inadequate pain control.
C. The nurse should not independently administer a bolus without first assessing the PCA function and obtaining provider orders.
D. Encouraging the patient to push the button may not be effective if the pump is malfunctioning or if the lockout interval is preventing delivery. Assessment comes first.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Only the client should administer PCA medication. Allowing others to do so increases the risk of oversedation and respiratory depression.
B. This is a non-therapeutic response that can sound judgmental and does not address safety.
C. This encourages unsafe practice because only the patient should control PCA administration.
D. PCA pumps are designed for the client to self-administer analgesia based on their pain level. This prevents oversedation and ensures safe use of opioids.
Correct Answer is ["1.5"]
Explanation
Rationale:
Use the formula:
Number of tablets = Ordered dose ÷ Dose per tablet
Number of tablets = 150 mg ÷ 100 mg/tablet
Number of tablets = 1.5 tablets
Final Answer: 1.5 tablets
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