A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?
Inform the provider that the PCA is not providing adequate pain relief.
Ask the provider for a prescription to decrease the continuous rate.
Instruct the client to push the button more frequently.
Instruct the client's caregiver to push the PCA button when the client is resting.
The Correct Answer is B
A. Informing the provider that the PCA is not providing adequate pain relief is not accurate in this scenario because the client rates their pain as 2, indicating that they are experiencing minimal discomfort.
B. Asking the provider for a prescription to decrease the continuous rate is appropriate since the client has not needed to deliver any bolus doses for over 2 hours, suggesting that the current continuous rate may be higher than necessary for their pain level. Adjusting the PCA settings can help to prevent potential over-medication and side effects while maintaining adequate pain control.
C. Instructing the client to push the button more frequently is unnecessary as the client is already reporting low pain levels and has not expressed a need for additional medication.
D. Allowing the caregiver to push the PCA button when the client is resting is not recommended because PCA systems are designed for patient-controlled analgesia, ensuring that the patient manages their own pain without risking over-medication.
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Related Questions
Correct Answer is C
Explanation
A. Level of orientation refers to cognitive function and is not part of an anthropometric assessment.
B. Current pain level is subjective and not typically measured as part of an anthropometric assessment.
C. Weight is an essential component of anthropometric assessment, providing information about the client's nutritional status and health.
D. Respiratory rate is a vital sign and is not typically included in anthropometric assessments, which focus more on physical measurements.
Correct Answer is D
Explanation
A. This position does not optimize drainage of the left lower lobe. The affected lung should be positioned higher so that secretions can drain downward with gravity.
B. Supine position is not optimal for postural drainage of the lower lobes.
C. Prone position is typically used for postural drainage of the upper lobes, not the lower lobes.
D. For postural drainage of the left lower-lobe atelectasis, the client should be positioned right lateral in Trendelenburg position (head lower than feet). This positioning uses gravity to facilitate drainage of secretions from the affected lung segment, allowing them to move into larger airways where they can be coughed out or suctioned.
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