A nurse is caring for a client who is receiving acetaminophen for mild pain.
The nurse should monitor the client for which of the following adverse effects of this medication?

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.

Choice Arationale:

The statement about taking the medication with food is incorrect. Nitroglycerin sublingual tablets should not be taken with food. They work much faster when absorbed through the lining of the mouth.

Choice B rationale:

The statement that the medication can slow the heart rate is incorrect. Nitroglycerin does not slow the heart rate. In fact, it can cause a reflex tachycardia, where the heart rate increases.

Choice C rationale:

The statement that the effects of the medication should be felt within 5 minutes is correct. This indicates an understanding of the instructions.

Choice Drationale:

Taking the medication every 10 minutes until the pain goes away is incorrect. Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. However, if the pain is not relieved, a second tablet can be taken 5 minutes after the first tablet. If the pain continues for another 5 minutes, a third tablet may be used. Taking the medication every 10 minutes could lead to an overdose.