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 A rationale:

The gauge and length of needle used for an IM injection are important to document. This information can help track which supplies were used and can be useful for future reference.

Choice B rationale:

While it’s important to check the medication expiration date before administration, it’s not typically documented after administering medication.

Choice C rationale:

The dose of medication administered should always be documented. This helps ensure accurate medical records and allows healthcare providers to track how much of a medication a patient has received.

Choice D rationale:

The site of injection should be documented. This can help prevent complications such as repeated use of the same injection site.

Choice E rationale:

The time of administration should be documented. This helps keep track of when the patient received their medication, which is crucial for medications that need to be given at specific intervals.