Which is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PСА) pump?

Assess the abdomen for bowel sounds.

Initiate the dosage lockout mechanism on the PCA pump.

Instruct the client to use the medication before the pain becomes severe.

Assess the client's ability to use a numeric pain scale.

Answer and Explanation

The Correct Answer is B

A. Assess the abdomen for bowel sounds: Monitoring bowel sounds is important during opioid therapy because morphine can cause constipation. However, this assessment does not take priority when initiating PCA therapy, as it does not immediately affect safe administration or pain control.

B. Initiate the dosage lockout mechanism on the PCA pump: The lockout mechanism is the most critical safety feature of a PCA pump. It prevents the client from administering a second dose of medication before the first dose has had time to take effect. By strictly limiting the frequency of doses (e.g., a 6-to-10-minute lockout period), the pump prevents accidental overdose and toxicity. While all the listed options are part of the nursing process, ensuring the mechanical safety of the high-alert medication delivery system is the priority during the initiation phase.

C. Instruct the client to use the medication before the pain becomes severe: Teaching about preemptive use improves pain control and prevents breakthrough pain, but this instruction is most effective after determining that the client can understand and use the PCA system appropriately.

D. Assess the client's ability to use a numeric pain scale: The nurse must ensure the client can communicate their pain level to evaluate the effectiveness of the therapy. However, this is a baseline assessment that should ideally occur before the initiation of the pump. It does not carry the same immediate safety weight as securing the pump's lockout mechanism.

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Correct Answer is B

Explanation

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

A. Monitor for desquamation and normal flora overgrowth. B. Wash skin between application of topical antiparasitic doses. C. Keep the child's nails short and encourage use of hand mittens. D. Shave the body hair before applying the scabicide lotion.

Correct Answer is C

Explanation

A. Monitor for desquamation and normal flora overgrowth: While monitoring skin integrity is important, this does not directly prevent the primary complication of scabies, which is secondary bacterial infection from scratching.

B. Wash skin between application of topical antiparasitic doses: Washing between doses can remove the medication prematurely, reducing its effectiveness. The lotion should remain on for the prescribed time before being washed off.

C. Keep the child's nails short and encourage use of hand mittens: Trimming nails and using mittens reduce scratching and skin breakdown, which lowers the risk of bacterial superinfection, the main complication of scabies in children.

D. Shave the body hair before applying the scabicide lotion: Shaving is not recommended, as scabicide is effective when applied to the skin surface. Shaving may cause irritation and increase discomfort without improving treatment outcomes.

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Which is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PСА) pump?

Nursing Test Bank

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