Question

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

A. right shoulder immobilizer in place
B. confused to time and place
C. B/P 178/92 and pulse 118
D. rates pain an 8 on a 0 to 10 scale

Answer 1

A patient who is confused to time and place would cause a nurse to question the order for a PCA pump, as it requires a patient to understand and be capable of operating the device safely.

Step-by-step explanation:

The assessment finding that would cause a nurse to question the order for a patient controlled analgesia (PCA) pump would be a patient who is 'confused to time and place'. A PCA pump allows patients to administer their own pain medication within prescribed limits, and it requires the patient to understand and be capable of operating the device. If a patient is confused, they may not be able to use the PCA pump correctly, which could lead to under or overdosing. Assessment findings such as a right shoulder immobilizer in place, high blood pressure (B/P 178/92) and pulse (118), or reporting severe pain (rates pain an 8 on a 0 to 10 scale) do not inherently contraindicate the use of a PCA. Instead, these factors would be managed alongside PCA use. However, cognitive impairment, as seen in confusion, could jeopardize patient safety with a PCA pump.