A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management.
The nurse enters the room to find the client asleep and his partner pressing the button to dispense a dose of analgesia.
Which of the following responses should the nurse make?
"Your husband should decide when more medication is needed.”.
"Why do you think your husband needs more medication when he is asleep?".
"It's a good idea to help make sure your husband can sleep comfortably.”.
"Next time you think he needs more medication, call me and I'll push the button.”.
The Correct Answer is B
The correct answer is choice B. "Why do you think your husband needs more medication when he is asleep?"
Choice A rationale:
"Your husband should decide when more medication is needed.” This response is incorrect because it implies that the partner has the authority to decide when the client needs pain medication, which violates the purpose of a PCA pump. A PCA pump is specifically designed for client-controlled pain management, ensuring that the patient, not anyone else, controls when they receive pain medication. Allowing someone else to press the button can lead to overmedication and safety risks.
Choice B rationale:
"Why do you think your husband needs more medication when he is asleep?" This response is correct because it prompts the partner to reflect on their actions and provides an opportunity for the nurse to educate about the proper use of PCA pumps. It addresses the immediate issue without being confrontational and opens the door for further discussion on the importance of client safety and correct PCA use.
Choice C rationale:
"It's a good idea to help make sure your husband can sleep comfortably.” This response is incorrect as it endorses inappropriate and unsafe behavior. It encourages the partner to continue pressing the PCA button, risking the client's safety due to potential overmedication, which can lead to severe complications, such as respiratory depression.
Choice D rationale:
"Next time you think he needs more medication, call me and I'll push the button.” This response is incorrect because it contradicts PCA protocols and removes the control from the client. The nurse is responsible for monitoring the client’s pain and safety, not administering medication upon another person’s request. This approach also increases the risk of dosing errors and undermines the purpose of patient-controlled analgesia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The Neonatal Infant Pain Scale (NIPS) is commonly used to assess pain in newborns and infants. It evaluates multiple indicators of pain, including facial expression, crying, breathing patterns, and arms and legs' movements, to determine if a baby is in pain.
Choice B rationale:
The FACES pain rating scale for children is not typically used for infants, as it relies on a child's ability to point to or describe their pain using facial expressions.
Choice C rationale:
The Premature Infant Pain Profile (PIPP) Scale is used primarily for preterm infants and not typically for all newborns. It is more specific to certain populations.
Choice D rationale:
The FLACC Scale (Face, Legs, Activity, Cry, Consolability) is used for assessing pain in young children who may not be able to self-report. It's not specific to infants, and the NIPS is more appropriate for this population.
Correct Answer is B
Explanation
Choice A rationale:
Placing electrodes on all four extremities is not the initial step in using a Transcutaneous Electrical Nerve Stimulator (TENS) unit. It may not be necessary for the specific pain management needs of the patient and can be uncomfortable or impractical.
Choice B rationale:
This is the correct initial step when starting TENS treatment. The nurse should adjust the settings to a level below the threshold at which the patient feels a tingling sensation. This ensures that the treatment is comfortable and safe for the patient. The goal is to provide pain relief, not to induce discomfort.
Choice C rationale:
Turning the unit on before attaching it to the patient is not advisable. It's essential to connect the electrodes to the patient first and then turn on the TENS unit. This sequence helps prevent accidental electrical stimulation before the device is properly set up.
Choice D rationale:
Applying conductive jelly to uncoated electrodes is a step in preparing the electrodes for use, but it should be done after attaching the electrodes to the patient's skin. This choice does not address the initial step in TENS treatment, which is setting the stimulation level. .
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