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 A

Explanation

A. Providing a night light can help the client navigate their surroundings safely during the night and reduce the risk of falls.
B. Elevating full-length side rails can be a restraint and increase the risk of injury if the client attempts to climb over them.
C. Placing the bedside table too far away may make it difficult for the client to reach necessary items, increasing the risk of falls.
D. Maintaining a specific room temperature is not directly related to fall prevention unless extreme temperatures are present.

A. Obtain a prescription for a diuretic. B. Administer oxygen to the client. C. Administer epinephrine to the client. D. Stop the transfusion. E. Place the client in high-Fowler's position.

Correct Answer is ["A","B","D","E"]

Explanation

A. Diuretics are used to reduce the fluid overload.

B. Administering oxygen helps alleviate hypoxia and support respiratory function.

C. Epinephrine is not indicated for these symptoms and could exacerbate the situation.
D. Stopping the transfusion is essential if transfusion-related complications are suspected.
E. Placing the client in high-Fowler's position helps optimize respiratory function and reduce fluid overload.

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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

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