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    Ati 0926 med surg proctored exam

    A nurse is educating a client in a surgical unit. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

    Explanation & Rationale

    Rationale: Potential Condition: The client continues to report pain (7/10 → 5/10) despite use of the PCA pump. Vital signs are stable, oxygenation is normal, and no adverse opioid effects (like respiratory depression or allergic reaction) are present. This indicates post-operative pain that is not yet adequately controlled. Actions to Take: Educating about the lockout mechanism ensures the client understands safe and effective PCA use, preventing underuse due to misunderstanding. Administering supplemental analgesics may be necessary if the PCA alone does not achieve pain relief. Parameters to Monitor: Pain level should be reassessed to evaluate the effectiveness of interventions. Respiratory rate is critical to monitor when giving additional opioids, since oversedation can lead to respiratory depression.

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