A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient-controlled analgesia (PCA) infusion device.
Which of the following client statements indicates an understanding of the teaching?
"I should only use the device when it's absolutely necessary.”.
"I'll be careful about pushing the button so I don't overdose.”.
"I will ask my family to push the dose button when I am asleep.”.
"I should tell the nurse if I can't control my pain with this device.”.
The Correct Answer is D
Choice A rationale
Patient-controlled analgesia is designed to allow patients to manage their pain proactively. Waiting until the pain is severe before using the device can lead to inadequate pain control and increased discomfort. The goal of PCA is to maintain a consistent level of analgesia by allowing the patient to self-administer small doses as needed.
Choice B rationale
PCA devices are programmed with safety limits, including lockout intervals and maximum doses, to prevent accidental overdosing. While the patient should understand how to use the button, the primary responsibility for preventing overdose lies with the device's safety mechanisms and the healthcare team's programming.
Choice C rationale
Allowing family members to push the PCA button bypasses the safety mechanisms built into the device, which are based on the patient's demand for pain relief. This practice can lead to over-sedation and respiratory depression if the patient is not the one experiencing the pain and needing the medication. The patient must be the only one to activate the PCA device.
Choice D rationale
If the PCA device is not effectively controlling the patient's pain, it indicates a need for reassessment of the medication, dosage, or delivery method. The nurse can then collaborate with the provider to make necessary adjustments to ensure adequate pain management. This statement demonstrates the client's understanding of the importance of communicating their pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Dry, scaly patches on the elbows are more characteristic of psoriasis, a chronic autoimmune skin disorder. Psoriasis typically presents with well-defined, erythematous plaques covered with silvery scales, commonly found on extensor surfaces like elbows and knees.
Choice B rationale
Different pigmented patches in the genital area could suggest various dermatological conditions, such as tinea cruris or post-inflammatory hyperpigmentation, but are not typical findings associated with herpes zoster. Herpes zoster lesions follow a dermatomal distribution.
Choice C rationale
Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus. It characteristically presents with a painful, vesicular rash that follows the distribution of a sensory nerve pathway or dermatome. The pain often precedes the appearance of the rash.
Choice D rationale
Excessive hair growth, or hirsutism, is not a typical finding associated with herpes zoster. Hirsutism is usually related to hormonal imbalances or certain medications affecting androgen levels.
Correct Answer is B
Explanation
Choice A rationale
Basal cell carcinoma typically presents as a pearly or waxy bump, often with telangiectasia (small blood vessels) and a rolled border. While it can grow, it is less likely to exhibit irregular shape and significant color variation.
Choice B rationale
Malignant melanoma is characterized by the "ABCDE" criteria: asymmetry (irregular shape), border irregularity (notched, scalloped, or blurred), color variation (multiple shades of brown, black, red, white, or blue), diameter (usually larger than 6 mm), and evolving (change in size, shape, color, or elevation). The patient's report of an increased size and an irregularly shaped lesion with varying colors strongly suggests malignant melanoma, a serious form of skin cancer arising from melanocytes.
Choice C rationale
Squamous cell carcinoma often appears as a firm, red nodule or a scaly, crusty patch. While it can be irregular in shape and may grow, the description of varied colors is less typical of squamous cell carcinoma compared to melanoma.
Choice D rationale
Kaposi's sarcoma presents as red, purple, or brown blotches or nodules on the skin. It is associated with human herpesvirus 8 (HHV-8) and is more common in individuals with weakened immune systems. The description of an increasing, irregularly shaped, and multicolored lesion is not typical of Kaposi's sarcoma.
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