The nurse is providing client teaching about the use of a patient-controlled analgesia (PCA) pump. Which statement by the client indicates the need for more instruction about the PCA pump?

"The PCA pump is designed so I can try to maintain adequate pain relief."

"If I am asleep, one of my visitors can push the button for me."

"The nurse will check the PCA pump syringe to check how often I am needing a dose."

"I don't need to be afraid of overdosing because the pump has preset doses to prevent that."

Answer and Explanation

The Correct Answer is B

Rationale:
A. "The PCA pump is designed so I can try to maintain adequate pain relief.": This statement shows understanding that the client can self-administer doses to manage pain effectively, which is the primary purpose of a PCA pump.

B. "If I am asleep, one of my visitors can push the button for me.": PCA pumps are intended for use only by the patient to prevent overdose or medication errors. Allowing others to push the button, known as "proxy dosing," is unsafe and indicates a need for further teaching.

C. "The nurse will check the PCA pump syringe to check how often I am needing a dose.": This reflects correct understanding that nursing staff monitors PCA use, including frequency and dose administration, to ensure safety and efficacy.

D. "I don't need to be afraid of overdosing because the pump has preset doses to prevent that.": This shows understanding that PCA pumps have safety mechanisms, such as lockout intervals and dose limits, to minimize the risk of overdose.

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Correct Answer is B

Explanation

Rationale:
A. Explain that living wills cannot be followed by emergency personnel: Living wills are legally recognized documents that guide care preferences, but their applicability depends on the patient’s current clinical situation. Blanket statements dismissing the document are inappropriate and may cause mistrust.

B. Seek clarification of the type of advance directive the client has: Different advance directives, such as a living will or a DNR order, provide varying levels of guidance regarding resuscitation. Confirming the specific directive ensures that care aligns with the client’s legally documented wishes. This is the most accurate and patient-centered response.

C. Schedule a client and family conference to review the plan of care: While a conference may be useful for ongoing care planning, it does not immediately address the family’s question about why resuscitation was performed. Immediate clarification is the priority.

D. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: DNR bracelets may indicate resuscitation preferences but are not universally used. Verification should include reviewing the medical record and legal documentation, not solely relying on a bracelet.

A. Support the client in an upright position until the belt is removed. B. Ease the client to the floor while holding the gait belt securely. C. Advise the client to grab hold of the gait belt for added support. D. Use the gait belt to slowly guide the client back to the room.

Correct Answer is B

Explanation

Rationale:
A. Support the client in an upright position until the belt is removed: Trying to keep a falling client upright increases the risk of both client and nurse injury. It is unsafe and does not control the fall effectively.

B. Ease the client to the floor while holding the gait belt securely: Lowering the client safely to the floor using the gait belt protects the client from injury and minimizes risk to the nurse. This is the standard safe procedure for fall prevention during ambulation.

C. Advise the client to grab hold of the gait belt for added support: During a sudden fall, the client may not have the strength, coordination, or reaction time to grab the belt effectively, so this is not a safe or reliable action.

D. Use the gait belt to slowly guide the client back to the room: Attempting to redirect or guide the client while they are falling does not prevent injury and may worsen the fall. Safe lowering to the floor is the priority.

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The nurse is providing client teaching about the use of a patient-controlled analgesia (PCA) pump. Which statement by the client indicates the need for more instruction about the PCA pump?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?

Correct Answer is B

Explanation

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