A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective?

I will only need to be on this pain medication.

I need the nurse to notify me when it is time for another dose.

I feel less anxiety about the possibility of overdosing.

I can receive the pain medication as frequently as I need to.

Answer and Explanation

The Correct Answer is C

Choice A reason: Stating exclusive reliance on PCA suggests misunderstanding. Effective PCA teaching clarifies it’s part of a multimodal pain plan, potentially including other medications or therapies. This belief may limit comprehensive pain management, risking inadequate relief or prolonged recovery.

Choice B reason: Needing nurse notification for doses indicates misunderstanding. PCA allows patient-initiated dosing within programmed limits, promoting autonomy. This statement suggests reliance on external cues, undermining PCA’s purpose of self-controlled analgesia, potentially leading to delayed or inadequate pain relief.

Choice C reason: Feeling less anxious about overdosing shows understanding of PCA safety features, like lockout intervals and dose limits, preventing excessive administration. This reflects effective teaching, as patients confident in PCA’s safety can focus on pain management, improving compliance and outcomes.

Choice D reason: Believing medication can be received as frequently as needed is incorrect. PCA has programmed lockout intervals to prevent overdosing. This misunderstanding risks patient frustration or unsafe attempts to override limits, highlighting ineffective teaching about PCA’s controlled delivery system.

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Correct Answer is C

Explanation

Choice A reason: A recent hysterectomy typically does not require a suprapubic catheter unless complications like bladder injury occur. Urethral catheters are standard for postoperative urinary management, as the urethra is usually unaffected, making suprapubic catheters unnecessary for routine hysterectomy recovery.

Choice B reason: Menopause does not necessitate a suprapubic catheter. It may cause urinary symptoms like incontinence due to hormonal changes affecting pelvic floor muscles, but these are managed with behavioral or pharmacological interventions, not catheterization, which is irrelevant to menopausal physiology.

Choice C reason: A urethral stricture, narrowing the urethra due to scar tissue, obstructs urine flow, making urethral catheterization difficult or impossible. A suprapubic catheter bypasses the urethra, draining urine directly from the bladder, ensuring effective bladder management and preventing complications like retention or infection.

Choice D reason: An appendectomy does not typically require a suprapubic catheter. Postoperative urinary management, if needed, uses urethral catheters, as appendectomy does not affect urethral patency. Suprapubic catheters are reserved for conditions obstructing urethral access, which appendectomy does not cause.

A. Stop the enema and document that the client did not tolerate the procedure. B. Lower the height of the solution container. C. Encourage the client to bear down. D. Allow the client to expel some fluid before continuing.

Correct Answer is B

Explanation

Choice A reason: Stopping the enema entirely is premature and unnecessary for cramping, which is a common response to rapid fluid instillation. Documentation of intolerance is only appropriate if the procedure cannot be completed after attempting adjustments. This action fails to address the cramping’s cause, potentially delaying constipation relief and patient comfort.

Choice B reason: Lowering the solution container reduces the flow rate of the enema, decreasing intraluminal pressure in the colon. Cramping often results from rapid fluid instillation stretching the bowel. Slowing the flow allows the colon to accommodate the fluid, alleviating discomfort while continuing the procedure effectively.

Choice C reason: Encouraging the client to bear down is inappropriate as it may cause premature expulsion of the enema fluid, reducing its effectiveness in relieving constipation. Bearing down increases intra-abdominal pressure, potentially exacerbating cramping rather than alleviating it, and does not address the underlying cause of discomfort from fluid instillation.

Choice D reason: Allowing the client to expel fluid prematurely interrupts the enema’s purpose of softening stool and stimulating bowel movement. While it may temporarily relieve cramping, it reduces the procedure’s efficacy, potentially requiring a repeat enema, which increases patient discomfort and procedural risks like rectal irritation.

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A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse anticipates a suprapubic catheter for which patient?

Correct Answer is C

Explanation

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is B

Explanation

A nurse is assessing the characteristics of a patient's pain. Which question is not included in the pain assessment?

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