Morphine sulfate via intravenous patient-controlled analgesia (PCA) pump is prescribed for a client with severe chronic back pain. Thirty minutes after initiating the PCA pump, the practical nurse (PN) notes that the client has become lethargic. Which action should the PN take?
Reinforce PCA pump teaching.
Check the IV insertion site for swelling.
Determine the client's pain scale rating.
Measure the client's vital signs.
The Correct Answer is D
A. Reinforce PCA pump teaching: Teaching about PCA use is important, but it is not the immediate priority when a client shows signs of lethargy. Education can be addressed later, once the client’s condition has been stabilized and safety is ensured.
B. Check the IV insertion site for swelling: Inspecting the IV site for infiltration or phlebitis is a routine step, but it does not address the potential systemic effect of morphine causing central nervous system depression.
C. Determine the client's pain scale rating: Assessing pain level is typically part of routine evaluation for clients on PCA, but when lethargy develops, the focus must shift to assessing possible opioid toxicity rather than pain relief effectiveness.
D. Measure the client's vital signs: Obtaining vital signs is the most immediate and appropriate action. Respiratory depression, hypotension, or bradycardia may indicate opioid overdose or excessive sedation. Prompt assessment allows the PN to recognize early signs of morphine toxicity and intervene quickly to prevent respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 1, 6, 9 months, and boosters at 12 months of age and before entering school: This schedule does not align with the current recommended DTaP (diphtheria, tetanus, acellular pertussis) immunization timeline and could lead to gaps in protection against whooping cough.
B. Birth, 2 months, 12 months and boosters every 7 to 10 years: Infants are not vaccinated against pertussis at birth. This schedule incorrectly combines aspects of other vaccines and would leave the infant unprotected during the early high-risk months.
C. 2, 4, 6 months, and boosters at 15 to 18 months and 4 to 6 years of age: This schedule follows the CDC-recommended DTaP series, providing early protection during infancy and reinforcing immunity with booster doses in toddlerhood and early school age, which is crucial for preventing whooping cough.
D. 1 year of age, 6 years of age, and with each exposure: Delaying the initial series until 1 year leaves infants unprotected during a vulnerable period, and “with each exposure” is not part of standard immunization recommendations.
Correct Answer is B
Explanation
A. Impaired verbal communication: While difficulty expressing feelings may occur after IVF failure, it does not immediately threaten the client’s emotional or physical well-being and is lower priority compared to coping.
B. Ineffective individual coping: Emotional distress after a failed IVF attempt can significantly affect mental health, daily functioning, and decision-making. Supporting effective coping is the highest priority to prevent depression, anxiety, or maladaptive behaviors.
C. Altered sexuality patterns: Concerns about sexual intimacy may develop following infertility treatment, but these issues are secondary to the client’s immediate coping and emotional adjustment needs.
D. Impaired social isolation: Social withdrawal can occur due to emotional distress, but it is a consequence of ineffective coping. Addressing coping strategies first helps prevent or reduce social isolation.
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