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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. It is a medical emergency that requires treatment in a hospital, but it is not contagious.

Choice B reason: An older adult client admitted with aspiration pneumonia would not typically require a private room solely based on this condition. Aspiration pneumonia is caused by inhaling food, stomach acid, or saliva into the lungs. It can lead to a bacterial infection, which may or may not be contagious depending on the causative organism.

Choice C reason: A client with a compound fracture of the right femur would not require a private room based on the diagnosis alone. A compound fracture, also known as an open fracture, is a fracture in which there is an open wound or break in the skin near the site of the broken bone. While it requires immediate medical attention to prevent infection, it is not a condition that necessitates isolation.

Choice D reason: A client who reports having fever, night sweats, and cough for 2 days may require a private room due to the possibility of an infectious disease that could be transmitted to others, such as tuberculosis (TB). These symptoms are concerning for TB, which is an airborne infectious disease and would require airborne precautions, including a private room with negative pressure ventilation.

A. Instruct the client to avoid eating raw vegetables. B. Initiate a referral for the client to a home health agency. C. Remind the client of the importance of medication adherence. D. Tell the client to avoid places where there are large crowds of people.

Correct Answer is B

Explanation

Choice A reason: Instructing the client to avoid eating raw vegetables may be a precautionary measure due to potential immunosuppression from AIDS, but it does not directly demonstrate advocacy. Advocacy would involve actions that support the client's rights, choices, and interests, and while dietary advice is important, it is not an advocacy action in itself.

Choice B reason: Initiating a referral for the client to a home health agency is a clear demonstration of client advocacy. This action shows that the nurse is taking steps to ensure the client receives the necessary support to manage their condition at home, respecting their wish to maintain independence and quality of life.

Choice C reason: Reminding the client of the importance of medication adherence is part of the nurse's educational role but does not necessarily reflect advocacy. Advocacy would involve more proactive measures to support the client's treatment and care decisions.

Choice D reason: Telling the client to avoid places where there are large crowds of people is good advice to reduce the risk of infections, but it is not an advocacy action. Advocacy involves representing the client's interests and facilitating their choices and access to care.

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