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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Setting the hot water heater to a lower temperature reduces the risk of burns and scalds, which is appropriate for an older adult with osteoporosis. Lowering the water heater temperature to around 49°C (120°F) or less is recommended to prevent scalds.

B. Installing grab bars in the shower enhances safety and prevents falls, which is important for an older adult with osteoporosis.

C. Storing prescriptions in a medication organizer promotes medication adherence, which is beneficial for an older adult with osteoporosis.

D. An area rug covering a tile floor increases the risk of slips, trips, and falls, which can lead to fractures in an older adult with osteoporosis. Removing the rug or securing it properly can help prevent accidents.

A. A nurse begins a blood transfusion without obtaining consent from a client. B. An assistive personnel discusses client care in the facility cafeteria with visitors present. C. A nurse administers a medication without first identifying the client. D. An assistive personnel prevents a client from leaving the facility.

Correct Answer is C

Explanation

A. Beginning a blood transfusion without consent is a breach of ethical principles, but it's not specifically negligence unless harm results.
B. Discussing client care in a public area violates privacy regulations and facility policy but is not an example of negligence.
C. Administering medication without properly identifying the client violates standard procedures and could lead to medication errors, which is a form of negligence.
D. Preventing a client from leaving the facility may be necessary to ensure their safety, depending on the circumstances, and is not necessarily an example of negligence.

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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?

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Naxlex Comprehensive Predictor Exams

A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

Correct Answer is D

Explanation

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?

Correct Answer is C

Explanation

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