A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?
a. Client who appears to be sleeping soundly
b. Client with no bolus request in 6 hours
c. Client who is pressing the button every 10 minutes
d. Client with a respiratory rate of 8 breaths/min
ANS: D
Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.
You might also like to view...
Jonas Roundy, 68 years old, had a cerebrovascular accident (CVA) 7 months ago. The physical and occupational therapy staff are very concerned regarding his slow progress
Which of the following rehabilitation principles should guide his rehabilitation? a. Convalescence is a gradual process that can take a long time b. The duration of rehabilitation depends on the psychological acceptance of the older adult of his or her condition c. Loss and its meaning vary with every person d. Values are examined and limitations are put in perspective over time
Which medication interferes with an important life process of a bacterial organism, making it weaker or incapable of reproducing?
a. Pathogenic b. Bacteriostatic c. Bactericidal d. Microbial
A middle-aged client with diabetes mellitus is being treated for the third episode of acute pyelonephritis in the past year and asks what can be done to help prevent these infections. Which is the nurse's best response?
a. "Test your urine daily for the presence of ketone bodies and proteins." b. "Use tampons rather than sanitary napkins during your menstrual period." c. "Drink more water and empty your blad-der every 2 to 3 hours during the day." d. "Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled."
The nurse is assessing an adolescent patient during a health maintenance visit. Which assessment finding would cause the nurse to suspect the adolescent is participating in the choking game?
1) Stomach pain 2) Red eyes 3) Chronic cough 4) Constipation