17. A client who is postoperative needs to walk, but even turning in bed is very painful. A patient-controlled analgesia (PCA) pump is set with a lock-out of 6 minutes. A nurse notes 45 attempts to get medication and 2 injections received in the last 2 hours. The correct nursing action is to:
. Get client out of bed now while pain level is low.
. Teach client how and why to use the pump more effectively.
. Record client's refusal to get out of bed.
. Push pain button before getting client out of bed.
Test-Taking Tip
Look for the option that is different from the others. Three of the options refer to "getting out of bed."
Content Area: Adult Health, Pain Control; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Pharmacological Pain Management
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Answer 1 is incorrect because, if the pain level is too high for the client to turn in bed, the client will not do well with walking. Answer 2 is correct because, with lock-out of 6 minutes, the client could have received 20 injections over the last 2 hours, yet only received 2. The high pain level will prevent the client from engaging in health promoting activities: 45 attempts indicates that the client wants more medicine. Teaching is required to help the client spread out the attempts. Answer 3 is incorrect because the nurse might record it if the client refuses ambulation, but it would be better to help the client control the pain to make ambulation possible. Answer 4 is incorrect because only the client should push the PCA button. This helps prevent overdoses.