A nurse is educating a client in a surgical unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale:
- Potential Condition: The client continues to report pain (7/10 → 5/10) despite use of the PCA pump. Vital signs are stable, oxygenation is normal, and no adverse opioid effects (like respiratory depression or allergic reaction) are present. This indicates post-operative pain that is not yet adequately controlled.
- Actions to Take:
- Educating about the lockout mechanism ensures the client understands safe and effective PCA use, preventing underuse due to misunderstanding.
- Administering supplemental analgesics may be necessary if the PCA alone does not achieve pain relief.
- Parameters to Monitor:
- Pain level should be reassessed to evaluate the effectiveness of interventions.
- Respiratory rate is critical to monitor when giving additional opioids, since oversedation can lead to respiratory depression.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Only the client should push the PCA button. Allowing others to administer doses increases the risk of oversedation and respiratory depression.
B. The lock-out interval prevents multiple doses from being delivered in a short period, ensuring safe administration.
C. Lock-out intervals vary (often 5–15 minutes) depending on the medication and provider order, not a fixed 30 minutes.
D. The client should assess their pain using the pain scale and self-administer medication as needed within the safety parameters of the PCA pump.
Correct Answer is B
Explanation
Rationale:
A. Acetazolamide, a carbonic anhydrase inhibitor, decreases aqueous humor production, but oral administration acts more slowly and is not the priority in acute angle-closure glaucoma.
B. Mannitol, an osmotic diuretic, is given intravenously to rapidly decrease intraocular pressure by drawing fluid from the eye into the bloodstream. This is the priority medication to prevent permanent vision loss.
C. Betaxolol, a beta-blocker, helps reduce intraocular pressure but acts more slowly than IV mannitol and is not the first-line emergency intervention.
D. Morphine may help with pain but does not address the dangerously elevated intraocular pressure that threatens vision in acute angle-closure glaucoma.
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