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    ATI Adult health proctored exam (med surg)

    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 another dose. Which of the following responses should the nurse make?

    Explanation & Rationale

    Choice A rationale While the partner's intention may be good, allowing someone other than the client to administer PCA medication bypasses the safety mechanisms built into the pump and disregards the client's ability to self-titrate based on their pain level. This could lead to over-sedation and respiratory depression. Choice B rationale Patient-controlled analgesia is designed to allow clients to manage their own pain by self-administering medication within prescribed limits. The client is the best judge of their pain intensity and medication needs. Allowing the partner to push the button undermines this principle of patient autonomy and safety. Choice C rationale The nurse should not administer PCA medication based on a third party's assessment of the client's needs. This still circumvents the client's control and the safety features of the pump. The nurse's role is to assess the client directly and educate the client and family on proper PCA use. Choice D rationale While it's important to understand the partner's reasoning, the immediate concern is the inappropriate administration of medication. Addressing the partner's actions directly and educating them on the proper use of the PCA pump is the priority.

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