A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following actions should the nurse take?
Encourage family members to press the PCA button for the client.
Monitor the client's respiratory status every 4 hours.
Teach the client how to self-medicate using the PCA device.
Administer an oral opioid for breakthrough pain.
The Correct Answer is C
Choice A reason: Encouraging family members to press the PCA button for the client is not recommended. The PCA device is designed to be used by the patient to manage their own pain. Allowing someone other than the patient to administer the medication can lead to over-sedation or respiratory depression. The patient must have control over the PCA device to ensure that they are receiving the medication based on their pain level and not someone else's perception of their pain.
Choice B reason: Monitoring the client's respiratory status every 4 hours is important but may not be sufficient for a patient receiving morphine via a PCA device. According to clinical guidelines, respiratory rate, sedation, and pain scores must be recorded more frequently after the initiation of PCA therapy—typically every 15 minutes for the first hour, then every 30 minutes for the next 2 hours, and hourly until 24 hours post-operation. This is to ensure early detection of any adverse effects such as respiratory depression, which is a risk with opioid administration.
Choice C reason: Teaching the client how to self-medicate using the PCA device is the correct action. Patient education is crucial for the effective use of PCA. The patient should be instructed on how to use the device, including when to press the button and the importance of only the patient controlling the button. This empowers the patient to manage their pain effectively and safely, ensuring that they receive the medication when needed and reducing the risk of over-sedation or under-medication.
Choice D reason: Administering an oral opioid for breakthrough pain may be necessary if the PCA does not adequately control the patient's pain. However, this should be done cautiously and typically under the guidance of a pain management team or physician. Breakthrough pain medication is usually reserved for instances where the PCA is not providing sufficient pain relief, and the patient's pain is assessed to be higher than what can be managed by the PCA alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.
Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.
Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.
Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.
Correct Answer is D
Explanation
Choice A reason: Applying antibiotic ointment to the lesions is not recommended for the treatment of genital herpes, which is caused by a virus, not bacteria. Antiviral medications are the appropriate treatment for managing herpes outbreaks.
Choice B reason: Natural skin condoms are not effective in preventing the transmission of genital herpes because the virus can pass through the natural membrane. The use of latex or polyurethane condoms is recommended as they are more effective in reducing the risk of transmission.
Choice C reason: Expecting lesions to resolve in 6 weeks may not be accurate as the duration of a herpes outbreak can vary. Most herpes lesions tend to resolve within 2 to 4 weeks. However, the virus remains in the body and can cause recurrent outbreaks.
Choice D reason: The duration of medication for genital herpes depends on whether the treatment is for an initial outbreak, chronic suppression, or episodic therapy. For an initial outbreak, antiviral medication is typically taken for 7 to 10 days. For chronic suppression, medication might be taken daily for an extended period to prevent or reduce the frequency of outbreaks.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today