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 B
Explanation
A. Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.
B. This is the safest method to prevent accidental dislodgement of the tracheostomy tube. By securing the new ties first, the tracheostomy tube remains in place, reducing the risk of complications.
C. A secure knot that can be released quickly in case of emergency is recommended.
D. Extending the client's neck during tie securing can cause discomfort and respiratory compromise. The client's neck should be in a neutral position.
Correct Answer is A
Explanation
A. Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.
B. The nurse should not mix the medications together in a single syringe, because they might interact or precipitate.
C. The nurse should not combine the medications with the formula in the feeding bag, because this can alter the osmolality and nutrient content of the formula.
D. While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.
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