Question

The nurse is caring for a post-surgical client who is using patient controlled analgesia (PCA) with morphine for pain management. The client reports that the pain is severe and does not get better, even after "pushing the PCA button". Indicate the sequence of actions the nurse should take in the correct order.

1 Verify that the client is using the PCA equipment correctly.
2 Check the MAR for adjuvant medications.
3 Confirm that the pump is working and the tubing is patent.
4 Offer non-pharmacological interventions.
5 Consult with the health care provider.

1, 3, 2, 4, 5

1, 2, 3, 4, 5

5, 4, 1, 2, 3

4, 5, 1, 2, 3

Answer 1

The nurse should take the following actions in sequence: check the pump and tubing, verify correct use of the PCA equipment, check the MAR for adjuvant medications, offer non-pharmacological interventions, and consult with the health care provider.

Step-by-step explanation:

1. Confirm that the pump is working and the tubing is patent.
2. Verify that the client is using the PCA equipment correctly.
3. Check the MAR for adjuvant medications.
4. Offer non-pharmacological interventions.
5. Consult with the health care provider.

The correct sequence of actions the nurse should take is 3, 1, 2, 4, 5. First, the nurse should confirm that the pump is working and the tubing is patent to ensure that the client is receiving the medication. Then, the nurse should verify that the client is using the PCA equipment correctly. Next, the nurse should check the Medication Administration Record (MAR) for any adjuvant medications that may need to be administered. After that, the nurse should offer non-pharmacological interventions, such as relaxation techniques or positioning, to help alleviate the client's pain. Finally, if the client's pain is still severe and not improving, the nurse should consult with the health care provider.