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.”.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Sedatives and hypnotics are not typically recommended for long-term relief of sleep problems. They are more commonly used for short-term management of insomnia or acute sleep disturbances. Using these medications for an extended period can lead to tolerance, dependence, and potential side effects.

Choice B rationale:

Neuritis secondary to diabetes is not directly related to the use of sedatives and hypnotics for sleep. This choice does not affect the true or false statement about the long-term use of these medications.

Choice C rationale:

A severely sprained ankle does not impact the use of sedatives and hypnotics for sleep. This choice is not relevant to the true or false statement regarding the long-term use of these medications.

Choice D rationale:

Impaired peripheral circulation is not a determining factor for the long-term use of sedatives and hypnotics for sleep. This choice does not influence the true or false statement in question.

A. Constipation. B. Hypoventilation. C. Nausea. D. Headache.

Correct Answer is B

Explanation

Choice A rationale:

Constipation is not a common adverse effect of pain medication administered by the epidural route. Pain medication primarily affects the central nervous system and does not typically impact the gastrointestinal system in a way that would lead to constipation.

Choice B rationale:

Hypoventilation is the correct answer. When opioids or other potent pain medications are administered by the epidural route, they can depress the respiratory center in the brain, leading to hypoventilation (slow or inadequate breathing). This is a critical concern and the most important adverse effect to monitor because it can lead to respiratory compromise or even respiratory arrest.

Choice C rationale:

Nausea can be a side effect of some pain medications, but it is not the most important adverse effect to monitor in a patient receiving epidural pain medication. Nausea can often be managed with antiemetic medications.

Choice D rationale:

Headache is not a common adverse effect of epidural pain medication. The administration of pain medication into the epidural space is localized to the spinal area and does not typically lead to headaches.

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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?

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Medication such as sedatives and hypnotics are sometimes prescribed to promote sleep. These can be used for long-term relief.

Correct Answer is B

Explanation

A nurse is assisting in the care of a patient who is receiving pain medication by the epidural route.It is most important to monitor this patient for which adverse drug effects?

Correct Answer is B

Explanation

There are several different types of pain.Which type of pain occurs after the loss of a body part from an amputation?

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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?