a nurse is caring for a client who is receiving pain medication through a pca pump which of the following actions should the nurse take

ATI RN

ATI Leadership Proctored Exam 2019

1. When 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.

2. A client is having difficulty breathing while receiving supplemental oxygen via a nasal cannula in a supine position. Which of the following interventions should the nurse take first?

A. Suction the client's airway.
B. Instruct the client to perform incentive spirometry every hour.
C. Assist the client to an upright position.
D. Humidify the client's supplemental oxygen.

Correct answer: C

Rationale: When a client is experiencing difficulty breathing, the priority intervention is to assist the client to an upright position. This position helps improve ventilation by maximizing lung expansion and promoting better oxygenation. Suctioning the airway may be necessary if there is an obstruction, but repositioning the client is the initial step. Instructing the client to perform incentive spirometry and humidifying oxygen are important interventions but not the first priority in this scenario.

3. Which of the following would be considered an urgent and important issue?

A. Replacing two staff who were injured while caring for a violent patient
B. Updating the employee break room with new furniture
C. Preparing educational packets on self-administration of insulin for patients
D. Arranging a team-building event for staff members

Correct answer: A

Rationale: The correct answer is A because replacing staff injured while caring for a violent patient is both urgent and important. This issue directly relates to staff safety and patient care, requiring immediate attention. Choice B is not urgent or crucial to patient care. Choice C is important but may not be as urgent as the situation in choice A. Choice D is not as critical as replacing injured staff, making it a less urgent and important issue.

4. What is the major difference between managers and leaders?

A. Leaders usually have legitimate power.
B. Leaders do not necessarily make good managers.
C. Managers are not always leaders.
D. Managers always have legitimate power.

Correct answer: D

Rationale: The major difference between managers and leaders is that managers always have legitimate power. This is because managers derive their authority from their position within an organization, giving them legitimate power over subordinates. On the other hand, leaders do not always have legitimate power; their influence may come from various sources such as expertise, charisma, or the ability to inspire others. Choice A is incorrect because not all leaders necessarily have legitimate power. Choice B is incorrect as it is a generalization that leaders do not make good managers, which is not always the case. Choice C is incorrect as there can be managers who are also effective leaders.