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 B
Explanation
A. An allergic response typically presents with symptoms such as rash, itching, and swelling, not severe nausea and vomiting.
B. Disulfiram causes severe nausea and vomiting when alcohol is consumed, as part of its mechanism to deter drinking.
C. Severe nausea and vomiting are not common side effects unless alcohol is consumed.
D. Overdose might cause more severe systemic effects, not just nausea and vomiting.
Correct Answer is D
Explanation
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.
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