A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?
"I gave my client a bolus dose of morphine when I initiated the PCA pump."
"I noted that my client pushed the PCA button six times in the last hour, and the PCA lockout is set for 10 minutes."
"I told the client's family that they must not push the PCA button for the client."
"I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it."
The Correct Answer is D
A. Administering a bolus dose of morphine at PCA initiation is a common practice.
B. Monitoring the frequency of button presses and understanding the lockout period is appropriate.
C. Educating the family not to push the PCA button is correct and ensures patient safety.
D. Discarding the remaining medication should be witnessed and documented correctly, but the process should follow the institution’s protocol, and witnessing should have been done before discarding, not after.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Montelukast is taken once daily in the evening to help control asthma symptoms.
B. Montelukast is not used as a rescue medication during an asthma attack; it is for maintenance therapy.
C. A spacer device is used with inhaled medications, not with montelukast, which is taken orally.
D. Rinsing the mouth is recommended after using inhaled corticosteroids, not montelukast.
Correct Answer is ["13"]
Explanation
Total volume and infusion time:
Volume (ml) = 1200 mL
Time (hours) = 24 hours
Conversion to ml/hr:
ml/hr = Volume (ml) / Time (hours)
ml/hr = 1200 ml / 24 hours
ml/hr = 50 ml/hr
Drop factor and conversion to gtt/min:
Drop factor = 15 gtt/mL
gtt/min = ml/hr * Drop factor
gtt/min = 50 ml/hr * 15 gtt/mL
gtt/min = 750 /60= 12.5 gtt/min
= 13 gtt/min (rounded off to the nearest whole number)
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