A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?
a. Assess and record vital signs every 2 hours.
b. Have another nurse double-check the pump settings.
c. Instruct the client to report any unrelieved pain.
d. Monitor for numbness and tingling in the legs.
ANS: B
PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double-checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; monitoring does not prevent the event from occurring.
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