Nokea
A client is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?
- A. Educate the family not to push the button for the client while the client is asleep.
- B. Explain to the client that vital signs will be monitored regularly due to being on a PCA pump.
- C. Instruct the client to push the button only when pain is above a 7 on a scale of 0 to 10.
- D. Adjust the basal rate and decrease the lock-out interval time if the client's pain level is too high.
Correct Answer: D
Rationale: When a client is receiving pain medication through a PCA pump, it is essential to adjust the settings if their pain level is not adequately controlled. Increasing the basal rate and shortening the lock-out interval time can help manage the client's pain more effectively. This adjustment should be made by the healthcare provider based on the client's pain assessment and response to the current settings. It is crucial to individualize the PCA pump settings to optimize pain management for each client. Choices A, B, and C are incorrect because educating the family not to push the button, explaining vital sign monitoring, and setting a specific pain level for button pushing are not direct actions the nurse should take to adjust the PCA pump settings for effective pain management.
You may also like to solve these questions
After receiving change-of-shift report, which patient should the nurse assess first?
- A. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12%
- B. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL
- C. 40-year-old who is pregnant and has an oral glucose tolerance test result of 202 mg/dL
- D. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain
Correct Answer: B
Rationale: The patient with a blood glucose level of 40 mg/dL (hypoglycemia) needs immediate attention as it is an emergency situation that requires prompt intervention to prevent adverse effects. Severe hypoglycemia can lead to serious complications, such as seizures or loss of consciousness. Therefore, the nurse should prioritize assessing and managing this patient first to prevent further deterioration. Choices A, C, and D do not present immediate life-threatening situations requiring urgent intervention like severe hypoglycemia does. A high hemoglobin A1C level, an abnormal oral glucose tolerance test result, and acute abdominal pain, while important, do not pose an immediate threat to the patient's life compared to severe hypoglycemia.
Under which category does a violation of the nurse practice act fall?
- A. Juvenile
- B. Felony
- C. Misdemeanor
- D. Tort
Correct Answer: D
Rationale: A violation of the nurse practice act falls under the category of tort. Tort refers to civil wrongs that cause harm or loss to another person, and a violation of the nurse practice act can result in a civil lawsuit against the nurse for negligence or malpractice. Choices A, B, and C are incorrect because a violation of the nurse practice act does not fall under juvenile offenses, felonies, or misdemeanors, but rather under civil wrongs known as torts.
What is the main goal of discharge planning?
- A. To ensure that patients are discharged as quickly as possible
- B. To prevent hospital readmissions
- C. To educate patients about their medications
- D. To transition patients from one level of care to another
Correct Answer: B
Rationale: The main goal of discharge planning is to prevent hospital readmissions by ensuring patients have a clear and effective plan for post-discharge care. This includes coordinating follow-up appointments, medication management, and providing necessary support services to promote a successful transition from the hospital to home or another care setting. Choices A, C, and D are incorrect because discharge planning is not primarily about speedy discharge, medication education, or transitioning between care levels; its main focus is on preventing readmissions through comprehensive post-discharge care.
In the scenario where a family member slips on the wet floor and hits her head, what hospital process requires completion of an incident report?
- A. Risk management
- B. Outcome management
- C. Quality management
- D. Peer review
Correct Answer: A
Rationale: In healthcare settings, completing an incident report is a crucial aspect of risk management. Risk management aims to identify, assess, and mitigate risks to prevent harm to patients, visitors, or staff. Incident reports provide valuable data for analyzing events, implementing corrective actions, and improving patient safety within the healthcare facility. Choices B, C, and D are incorrect because outcome management focuses on achieving desired results, quality management concentrates on maintaining high standards of care, and peer review involves evaluating the performance of healthcare providers, none of which directly relate to the completion of an incident report due to an accident.
Staff refuse to report unsafe conditions, with unattended entrances throughout the health care facility noted. Unidentified individuals are wandering the unit at night, and you:
- A. Establish expectations.
- B. Demand that they leave immediately.
- C. Ask them to leave.
- D. Observe their behaviors.
Correct Answer: A
Rationale: In this scenario, the correct course of action is to establish expectations. By setting clear guidelines and expectations, you can address the issue of unidentified individuals wandering the unit at night in a proactive manner. This approach helps communicate what behaviors are acceptable, ensuring the safety of both staff and patients. Demanding that they leave immediately or simply observing their behaviors may not effectively address the root cause of the problem and could potentially escalate the situation. Asking them to leave without establishing expectations may not prevent similar incidents from occurring in the future.