The nurse is caring for a patient who will be using a hydromorphone (Dilaudid) PCA analgesia pump following surgery. Which intervention is the highest priority for the nurse to include in the patient's care plan for the diagnosis:
Readiness for enhanced knowledge r/t appropriate management of PCA pump?
a.
Assess the patient's respiratory status every 30 minutes after PCA pump started.
b.
Review patient's medication profile to check for interactions with hydromorphone.
c.
Teach the patient how to use PCA pump when awake and aware and pain level is tolerable.
d.
Keep naloxone (Narcan) available at the bedside in case of respiratory suppression.
ANS: C
Interventions for the nursing diagnosis: Readiness for enhanced knowledge include teaching the about pain medication use when the patient is ready to learn. The other interventions do not apply to the enhanced knowledge nursing diagnosis.
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