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 C
Explanation
Choice A rationale:
Taking a warm bath before trying to go back to sleep is a relaxation technique that may help with sleep but does not address the underlying causes of insomnia. It is more of a short-term coping strategy rather than a method for locating the reasons for the insomnia.
Choice B rationale:
Reviewing times in her life when she had no insomnia is not a practical approach to addressing the current issue of insomnia. It does not help in identifying the specific factors or triggers contributing to the patient's current sleep problems.
Choice C rationale:
Keeping a diary related to sleep and problems encountered is a practical and effective approach to identify the factors contributing to the patient's insomnia. This diary can help track patterns, such as bedtime routines, diet, stressors, and other variables that may be linked to the sleep problem. Identifying these factors can aid in developing a plan to address the specific causes of the insomnia.
Choice D rationale:
Discussing the problem with her friends may provide emotional support but is unlikely to help identify the root causes of the insomnia. Friends may offer advice or share their experiences, but a structured approach like keeping a sleep diary is more likely to yield valuable information.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
Perception is one of the phases of nociceptive pain. It involves the awareness of pain, where the brain recognizes and interprets the pain signals. During this phase, the individual becomes conscious of the painful sensation.
Choice B rationale:
Transmission is another phase of nociceptive pain. It involves the propagation of pain signals from the site of injury or damage to the central nervous system. Nerve fibers carry the pain signals to the spinal cord and brain for processing.
Choice D rationale:
Modulation is also a phase of nociceptive pain. It refers to the body's ability to modify or regulate the pain signals. This can involve the release of endorphins or other natural pain-relieving substances that help dampen the pain perception.
Choice E rationale:
Transduction is the last phase of nociceptive pain. It is the process where the noxious stimulus (injury or damage) is converted into electrical nerve signals that the body can understand. This conversion allows the pain signal to travel through the nervous system.
Choice C rationale:
Translation is not typically considered one of the phases of nociceptive pain. While translation may refer to the process of converting one form of information to another, it is not a recognized phase in the context of pain perception.
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