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: Placing the client's bed at the lowest height is a safety intervention that minimizes the risk of injury from falls, which is particularly important for clients with dementia who may have impaired mobility or judgment. Lowering the bed height can reduce the severity of an injury if a fall does occur. Additionally, it can facilitate easier access for the client to get in and out of bed with less assistance.
Choice B reason: Requesting a prescription for a nightly sedative is not typically recommended as a first-line intervention for clients with dementia. Sedatives can increase the risk of confusion, falls, and can worsen cognitive impairment in the elderly. Non-pharmacological approaches are preferred for managing sleep disturbances in dementia patients.
Choice C reason: Assisting the client with toileting at least once every 4 hours is an important intervention to maintain hygiene and comfort, as well as to prevent urinary tract infections and skin breakdown. However, the frequency of toileting assistance should be individualized based on the client's needs and level of incontinence.
Choice D reason: Turning off all lights in the client's room at night is not advisable as some clients with dementia may experience increased confusion or agitation in complete darkness. A nightlight or low-level lighting can provide a safer environment and help to orient the client during nighttime hours.
Correct Answer is A
Explanation
Choice A reason: This response is appropriate because it encourages the client to seek professional medical advice, ensuring they receive personalized recommendations based on their health status and needs. It also emphasizes the importance of a physical examination to rule out any contraindications or underlying health issues before starting any contraceptive method.
Choice B reason: Storing the CPM machine on the floor when not in use is not recommended as it can pose a tripping hazard and may not comply with safety standards. The machine should be stored properly according to the manufacturer's instructions to ensure safety and maintain the equipment's integrity.
Choice C reason:While barrier methods are a good option for preventing both pregnancy and sexually transmitted infections (STIs), suggesting a specific method without a full assessment of the client's needs and preferences is not ideal. It is better to involve a healthcare provider in the decision-making process.
Choice D reason: Increasing the range of motion rapidly when the CPM machine is used intermittently is not advised. Adjustments to the range of motion should be made gradually and according to the client's tolerance and the surgeon's orders. Rapid increases can cause pain and may hinder the healing process.
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