A patient has a morphine sulfate patient-controlled analgesia (PCA) to control postoperative pain. When the nurse enters the room, the patient complains of pain. The nurse's first response is which of the following?
Ask the patient to rate the pain on a 0-to-10 scale.
Call the physician or health care provider immediately.
Check the patency of the patient's intravenous line.
Speak to the patient in a calming tone to reduce anxiety.
The Correct Answer is A
A. Ask the patient to rate the pain on a 0-to-10 scale. Pain is subjective, and the first step in pain management is assessment. Asking the patient to rate their pain helps determine the severity and whether adjustments to pain management are needed.
B. Call the physician or health care provider immediately. Contacting the provider may be necessary if the pain is uncontrolled, but the nurse must assess the pain level first before deciding if intervention is needed.
C. Check the patency of the patient's intravenous line. While an IV line is essential for PCA function, the priority is assessing the patient’s pain level before troubleshooting the equipment.
D. Speak to the patient in a calming tone to reduce anxiety. Although a calm demeanor is beneficial, it does not address the patient’s pain directly. Pain assessment is the first priority.
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Related Questions
Correct Answer is C
Explanation
A. Errors by the nurse assistant in measuring temperature. While improper technique can lead to inaccurate readings, consistent temperature fluctuations in a head injury patient are more likely due to hypothalamic dysfunction.
B. Increased vasodilatation of the superficial vessels contributing to excess heat losses. Vasodilation can play a role in heat loss, but it does not fully explain difficulty maintaining body temperature, which is primarily regulated by the hypothalamus.
C. The client's head injury causing interference with the function of the hypothalamus. The hypothalamus regulates body temperature, and a severe head injury can disrupt this function, leading to temperature instability (neurogenic fever or hypothermia) despite the absence of infection.
D. Choosing the wrong time of day to obtain vital signs. While body temperature naturally fluctuates throughout the day, major instability in temperature regulation is not due to the timing of measurement but rather an issue with the hypothalamus.
Correct Answer is D
Explanation
A. "The PCA will give additional pain medication whenever the button is pushed." PCA pumps have lockout intervals to prevent overdose, so pushing the button repeatedly will not always result in additional medication.
B. "Wait until the pain becomes severe before pushing the PCA button." PCA is most effective when used at the onset of pain rather than waiting until it becomes severe, which can make pain harder to control.
C. "The PCA will deliver medication through the IV until the pain is all gone." PCA provides controlled doses of medication but does not eliminate pain entirely. The goal is pain management, not complete pain relief.
D. "You or a designated family member are the only one who gets to push the PCA button—nobody else may do so." PCA is designed for patient-controlled use, and only the patient (or a designated, trained family member in special cases) should operate it to ensure proper dosing and safety.
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