A patient with a deep partial thickness burn has been receiving hydromorphone through patient-controlled analgesia (PCA) for 1 week. The nurse caring for the patient during the previous shift reports that the patient wakes up frequently during the night reporting pain. What action by the nurse is appropriate?
Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.
Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain.
Consult with the health care provider about using a different treatment protocol to control the patient's pain.
Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.
The Correct Answer is C
C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.
A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.
B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.
D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.
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Related Questions
Correct Answer is C
Explanation
C. Asking the client to wiggle their toes assesses motor function and nerve integrity. In a neurovascular assessment, intact nerve function is crucial, as impaired nerve function can manifest as weakness or paralysis.
A. This technique assesses the circulation in the lower extremity by checking for the presence, strength, and symmetry of the pulse. However, it assesses for vascular component proximal to the fracture.
B. Edema in the calf muscle is mostly used as a marker for deep venous thrombosis. Although it can affect circulation. It may be a late sign.
D. Significant differences in thigh circumference between the affected and unaffected limb may indicate vascular compromise or other issues. This is however, a late sign of vascular compromise.
Correct Answer is C
Explanation
C. A neurovascular assessment involves evaluating the circulation, sensation, and movement of the limb distal to the cast to ensure there are no signs of neurovascular compromise, such as decreased pulses, numbness, tingling, or weakness. Prompt identification of any neurovascular impairment is essential for preventing complications such as compartment syndrome.
A. Explaining discharge instructions is important for ensuring the client and their parents understand how to care for the cast at home. However, it is not the priority action.
B. Applying an ice pack to the casted leg can help reduce swelling and provide pain relief, but it is not the priority action immediately after the cast application.
D. Providing reassurance is important for alleviating anxiety and promoting a positive experience for the client and their parents. However, it is not the priority action.
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