The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on pa-tient-controlled analgesia (PCA)
What is the nurse's next action? a. Push the PCA control for the client.
b. Discontinue the PCA immediately.
c. Assess the client's respiratory status.
d. Keep the client awake as much as possible.
C
The client should be assessed further before action is taken. If the client cannot stay awake 24 hours after surgery, there may be other problems. The nurse should assess respiratory rate and depth and lung sounds, as well as oxygen status. The nurse should never push the PCA for the client, and pain should be assessed before decisions are made and interventions taken.
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