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 C

Explanation

A. Loosening the client's bed linens may be necessary for comfort but does not directly address pain relief.
B. Massaging the sacrum directly over a pressure injury can cause further damage and is not recommended.
C. Music therapy is a recognized nonpharmacological intervention for pain management. It can help distract the client and promote relaxation, thereby reducing the perception of pain.
D. Bright lights in the room may exacerbate the client's discomfort and are not specifically targeted at managing the pressure injury pain.

A. Use trochanter rolls beside the client's legs. B. Place the client's arms at their side when turning them. C. Logroll the client every 4 hr. D. Cross the client's ankles when lying supine.

Correct Answer is A

Explanation

A. Using trochanter rolls helps maintain proper alignment and prevent external rotation of the hips, reducing the risk of hip contractures and pressure injuries.
B. Placing the client's arms at their side when turning them may restrict movement and is not recommended for maintaining circulation and preventing contractures.
C. Logrolling is typically used for clients with spinal cord injuries to maintain spinal alignment but is not necessary for all immobile clients and may not be feasible or appropriate every 4 hours.
D. Crossing the client's ankles when lying supine can lead to pressure injuries and compromised circulation in the lower extremities.

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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 planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

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