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 C

Explanation

A. Phenytoin should be administered at a rate no faster than 50 mg/min.
B. Phenytoin should be diluted in normal saline, not dextrose, as it can precipitate.
C. Administering a saline solution after injection helps to ensure the drug is fully flushed through the IV line.
D. Phenytoin is often administered to control active seizures, so holding it would not be appropriate.

A. Return the medication to the pharmacy B. Give the medication. C. Discard the medication. D. Notify the provider.

Correct Answer is C

Explanation

A. Returning the medication to the pharmacy is not the immediate appropriate action.
B. Giving expired medication can be unsafe and ineffective.
C. Discarding the medication is the correct action to ensure patient safety.
D. Notifying the provider is unnecessary for the immediate action needed to ensure patient safety; discarding the expired medication is the correct step.

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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

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