Difficulty: Medium
Average Score: 68%
Simulated
A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense a dose of analgesia. Which of the following responses should the nurse make?
Correct answer
B
Rationale
Correct Answer: B
Rationale: Option B is the correct response as it encourages the partner to reflect on why they think the client needs more medication while he is asleep. This promotes critical thinking and ensures that the partner understands the importance of only administering medication when necessary. It also opens up a conversation to assess the client's pain level accurately. This response empowers the partner to be an active participant in the client's care while preventing unnecessary medication administration.
Summary of other choices:
A: Incorrect. This response implies that the partner can make decisions about medication administration, which is not appropriate as only the client should determine when more medication is needed.
C: Incorrect. This response does not address the issue of the partner administering medication without assessing the client's actual need for it.
D: Incorrect. This response does not address the immediate situation of the partner administering medication while the client is asleep and encourages them to do the same in the future without proper assessment.
Rationale: Option B is the correct response as it encourages the partner to reflect on why they think the client needs more medication while he is asleep. This promotes critical thinking and ensures that the partner understands the importance of only administering medication when necessary. It also opens up a conversation to assess the client's pain level accurately. This response empowers the partner to be an active participant in the client's care while preventing unnecessary medication administration.
Summary of other choices:
A: Incorrect. This response implies that the partner can make decisions about medication administration, which is not appropriate as only the client should determine when more medication is needed.
C: Incorrect. This response does not address the issue of the partner administering medication without assessing the client's actual need for it.
D: Incorrect. This response does not address the immediate situation of the partner administering medication while the client is asleep and encourages them to do the same in the future without proper assessment.