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 D

Explanation

A. Tinnitus is not a known adverse effect of acetaminophen.
B. Muscle pain is not a known adverse effect of acetaminophen.
C. Hyperglycemia is not a known adverse effect of acetaminophen.
D. Jaundice is an indication of liver damage, which can occur with excessive or long-term use of acetaminophen.

A. Fill out an occurrence form. B. Administer the medication to the correct client. C. Notify the client's provider. D. Check the client's vital signs.

Correct Answer is D

Explanation

A. Filling out an occurrence form is necessary but not the immediate priority.
B. Administering the medication to the correct client is important but not the immediate priority.
C. Notifying the provider is important but assessing the client's condition comes first.
D. Checking the client's vital signs is the immediate priority to ensure they are stable after the medication error.

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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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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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