A nurse is caring for a client who is postoperative and using a PCA pump. For which of the following actions should the nurse intervene?

The client administers a PCA dose prior to dressing changes

The client is ambulating with the PCA pump.

The client requests their partner administer PCA doses while they sleep.

The client administers a PCA dose as soon as their pain returns.

Answer and Explanation

The Correct Answer is C

A. Administering a PCA dose prior to dressing changes is appropriate for managing pain before potentially painful activities.

B. Ambulating with the PCA pump is acceptable, as long as the client is not disconnected and it does not interfere with the pump's function.

C. Requesting a partner to administer PCA doses is incorrect because only the patient should administer PCA doses to prevent overmedication and to ensure that the client is aware of their pain level.

D. Administering PCA doses as soon as pain returns is appropriate as long as the client follows the prescribed timing for PCA use.

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Correct Answer is D

Explanation

A. Epoetin alfa should be stored in the refrigerator but never frozen; thawing is not appropriate.

B. The medication should not be diluted prior to administration.

C. Shaking can denature the protein in the medication and is contraindicated.

D. A cloudy solution indicates contamination or degradation, and the medication should be discarded.

A. Vomiting 30 mL of fluid B. Urinary output of 20 mL within 1 hr C. Respirations deep at a rate of 10/min D. Blood pressure 90/60 mm Hg

Correct Answer is C

Explanation

A. Vomiting 30 mL of fluid is concerning but not immediately life-threatening in the context of morphine administration.

B. Urinary output of 20 mL in 1 hr is low, but it is not as urgent as respiratory depression.

C. Respirations deep at a rate of 10/min is a sign of respiratory depression, which is a priority concern in patients receiving opioids like morphine, as it can lead to hypoxia and respiratory failure.

D. Blood pressure 90/60 mm Hg is low but not as immediately concerning as respiratory depression in this scenario.

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A nurse is caring for a client who is postoperative and using a PCA pump. For which of the following actions should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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