A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?
"Using morphine PCA increases the client's risk of toxicity.”
"Diarrhea is an adverse effect of morphine PCA.”
"Check the client's pain level every 8 hours.”
"Instruct the client's visitors not to operate the PCA pump.”
The Correct Answer is D
Choice A rationale:
Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.
Choice B rationale:
Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.
Choice C rationale:
Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.
Choice D rationale:
Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Pinching the tube while connecting the syringe to it could potentially damage the tube and does not aid in medication administration.
Choice B rationale:
Elevating the head of the client’s bed to only 10° may increase the risk of aspiration. The head of the bed should be elevated to at least 30° during medication administration and for at least an hour afterward.
Choice C rationale:
Flushing the tube with normal saline following medication administration helps ensure that all medication has been administered and helps maintain tube patency.
Choice D rationale:
Combining crushed medications together in a single syringe can lead to drug interactions and can also increase the risk of tube clogging. Each medication should be administered separately.
Correct Answer is A
Explanation
Choice A rationale:
An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.
Choice B rationale:
A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.
Choice C rationale:
A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.
Choice D rationale:
A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.
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