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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. The client should be repositioned at least every 2 hr, or more frequently if indicated by the client's condition or risk assessment.
B. The nurse should avoid elevating the head of the client's bed more than 30°, unless contraindicated, to reduce shearing forces on the sacrum and heels.
C. Massaging bony prominences can increase the risk of pressure injuries by causing friction and shearing forces on the skin.
D. The nurse should use pressure-relieving devices, such as foam pads, pillows, or air mattresses, to protect the client's heels and other areas from direct contact with the mattress.

A. The client's temperature is 38.3° C (101° F). B. The client has a separation of their surgical incision. C. The client has 3+ pitting edema in the bilateral lower extremities. D. The client's urine output is 20 mL/hr.

Correct Answer is B

Explanation

A. While an elevated temperature may indicate infection, a separation of the surgical incision poses an immediate risk of dehiscence or evisceration and requires urgent attention.
B. A separation of the surgical incision is a serious complication that requires immediate intervention to prevent further complications such as infection or evisceration.
C. Pitting edema may indicate fluid retention but is not as immediately concerning as a surgical incision separation.
D. While decreased urine output may indicate renal dysfunction, it is not as urgent as a surgical incision complication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider first?

Correct Answer is B

Explanation

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