Question

A nurse is assessing a client who is postoperative and has a PCA. The client exhibits restlessness, and elevated pulse, and decrease blood pressure. Which of the following action should the nurse take?

a) Administer the prescribed pain medication through the PCA pump.
b) Check the client's vital signs again in 15 minutes.
c) Notify the healthcare provider of the client's symptoms.
d) Increase the PCA pump dosage without consulting anyone.

Answer 1

The nurse should immediately notify the healthcare provider of the postoperative client's symptoms of restlessness, elevated pulse, and decreased blood pressure. Increasing the PCA pump dosage or waiting 15 minutes before rechecking vitals could mask serious complications or delay necessary interventions.

Step-by-step explanation:

The patient who is postoperative with a PCA (Patient-Controlled Analgesia) and exhibits restlessness, an elevated pulse, and decreased blood pressure is displaying signs that may indicate complications, such as sepsis or hemorrhage, rather than simply inadequate pain control. While it might be tempting to administer more pain medication through the PCA pump, these symptoms can also be signs of serious conditions that require immediate medical attention.

C) Notify the healthcare provider of the client's symptoms is the most appropriate action. The healthcare provider can assess the situation, review the patient's overall condition, and decide whether these symptoms are related to postoperative pain or if they indicate a more severe problem that needs to be addressed urgently. It is critical that a nurse does not increase the PCA pump dosage without consulting a healthcare provider as this could exacerbate the patient's current condition or mask symptoms of a serious complication.

Additionally, whilst the symptoms are being evaluated, it would be prudent for the nurse to continuously monitor the client's vital signs, rather than waiting 15 minutes, to ensure timely intervention if the patient's condition deteriorates.