What information would be important for the nurse to reinforce when teaching a pre-operative client about the correct use of the patient-controlled analgesia (PCA) device to achieve the best outcome?

“Try to go as long as possible before you press the button.”

“Instruct your family or visitors to press the button for you when you are sleeping.”

“Push the button every 15 minutes whether you feel pain at that time or not.”

“Push the button when you begin to feel pain, instead of waiting until the pain becomes worse.”

Answer and Explanation

The Correct Answer is D

Choice A reason:

Telling the patient to “try to go as long as possible before you press the button” is not advisable. PCA devices are designed to allow patients to manage their pain effectively by administering medication as soon as they begin to feel discomfort. Delaying the use of the PCA can lead to uncontrolled pain, which can be more difficult to manage later.

Choice B reason:

“Instruct your family or visitors to press the button for you when you are sleeping” is incorrect and potentially dangerous. Only the patient should press the PCA button to ensure that they are receiving the medication when they actually need it. Allowing others to press the button can lead to overmedication and serious side effects.

Choice C reason:

“Push the button every 15 minutes whether you feel pain at that time or not” is also incorrect. PCA devices are intended to be used on an as-needed basis. Pressing the button at regular intervals without experiencing pain can result in unnecessary medication administration and potential overdose.

Choice D reason:

“Push the button when you begin to feel pain, instead of waiting until the pain becomes worse” is the correct instruction. This approach helps to manage pain more effectively by preventing it from becoming severe. Early intervention with pain management can lead to better overall outcomes and patient comfort.

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Correct Answer is D

Explanation

Early signs of hypoxia, which is a condition where the body or a region of the body is deprived of adequate oxygen supply, often include symptoms such as restlessness, confusion, and tachycardia (rapid heart rate). These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing heart rate and causing a state of agitation or confusion.

Choice A reason:

Bradycardia, lethargy, confusion are not typically early signs of hypoxia. Bradycardia (slow heart rate) is more commonly associated with severe or prolonged hypoxia rather than early stages. Lethargy and confusion can occur, but they are not as immediate as restlessness and tachycardia.

Choice B reason:

Hypotension, vomiting, cyanosis are also not early signs of hypoxia. Hypotension (low blood pressure) and cyanosis (bluish discoloration of the skin) are more advanced signs indicating severe hypoxia. Vomiting is not a common symptom of hypoxia and is more likely related to other conditions.

Choice C reason:

Bradycardia, dyspnea, cyanosis includes symptoms that are more indicative of advanced hypoxia. Dyspnea (difficulty breathing) and cyanosis are signs that the body has been deprived of oxygen for a longer period. Bradycardia is not an early sign and usually occurs later in the progression of hypoxia.

Choice D reason:

Restlessness, confusion, tachycardia are classic early signs of hypoxia. Restlessness and confusion occur due to the brain’s response to low oxygen levels, while tachycardia is the body’s attempt to increase oxygen delivery to tissues by pumping blood more rapidly. These symptoms are the body’s initial compensatory mechanisms to address the lack of oxygen.

A. Notify the surgeon and anesthesiologist. B. Assume that the client is confused because he is elderly. C. Ask the client to point to his good eye. D. Check to see if the client has received any preoperative medications.

Correct Answer is A

Explanation

Choice A reason: Notifying the surgeon and anesthesiologist is the most appropriate action. This ensures that the discrepancy is addressed immediately and the correct eye is operated on. It is crucial to verify and correct any inconsistencies in the surgical plan to prevent errors and ensure patient safety.

Choice B reason: Assuming that the client is confused because he is elderly is inappropriate and dismissive. Age should not be a factor in disregarding a patient’s statement. The nurse should take the client’s concerns seriously and verify the information rather than making assumptions about the client’s mental state.

Choice C reason: Asking the client to point to his good eye can help clarify the situation, but it is not sufficient on its own. While it may provide additional information, the nurse must still notify the surgical team to ensure that the correct procedure is performed. This step should be part of the verification process but not the sole action taken.

Choice D reason: Checking to see if the client has received any preoperative medications is important, but it does not address the immediate concern of the discrepancy in the consent form. The priority is to ensure that the correct eye is identified for surgery, and this requires notifying the surgical team.

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What information would be important for the nurse to reinforce when teaching a pre-operative client about the correct use of the patient-controlled analgesia (PCA) device to achieve the best outcome?

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