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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Dystonia involves sustained muscle contractions, not involuntary movements of the tongue and face.
B. Tardive dyskinesia is characterized by involuntary movements of the tongue, face, and other body parts, often as a result of long-term antipsychotic use.
C. Akathisia involves restlessness and the urge to move, not involuntary movements.
D. Parkinsonism involves symptoms similar to Parkinson's disease, such as tremor and rigidity, but not involuntary movements of the tongue and face.

A. "You should expect to experience diarrhea while taking this medication." B. "You should limit alcohol intake to 12 ounces daily." C. "You should take the medication on an empty stomach to prevent nausea." D. "You should change positions slowly.”

Correct Answer is D

Explanation

A. Diarrhea is not a common side effect of codeine; constipation is more likely.
B. Alcohol should be avoided while taking codeine due to increased risk of CNS depression.
C. Taking codeine on an empty stomach can increase the risk of nausea and gastrointestinal upset; it's better taken with food if necessary.
D. Codeine can cause dizziness or orthostatic hypotension, so changing positions slowly can help prevent falls and injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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