Question

When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. What is the nurse's best action?

Answer 1

The nurse's best action would be to closely monitor the drowsy client and notify the healthcare provider immediately.

Step-by-step explanation:

Based on the information provided, the nurse's best action would be to closely monitor the client and notify the healthcare provider immediately. A score of 4 on the Pasero & McCaffery Sedation Scale indicates that the client is moderately sedated and may require intervention to ensure their safety and well-being. Drowsiness and minimal response to physical stimulation suggest a potential adverse reaction to the PCA therapy, which should be promptly addressed by the healthcare team.