A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?
"Using morphine PCA increases the client's risk of toxicity.”
"Diarrhea is an adverse effect of morphine PCA.”
"Check the client's pain level every 8 hours.”
"Instruct the client's visitors not to operate the PCA pump.”
The Correct Answer is D
Choice A rationale:
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 C rationale:
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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Mixing insulin lispro and insulin glargine in the same syringe is not recommended. Insulin glargine has a different pH and mixing it with other insulins could affect its action.
Choice B rationale:
Insulin glargine is a long-acting insulin that is typically given once a day. It provides a steady level of insulin over a 24-hour period.
Choice C rationale:
Shaking insulin vials is not recommended as it can lead to inaccurate dosing. Instead, insulin vials should be gently rolled between the hands to ensure proper mixing.
Choice D rationale:
Insulin lispro is a rapid-acting insulin and should be taken right before a meal. This helps to control the blood glucose spike that occurs after eating.
Correct Answer is B
Explanation
Choice A rationale:
While headache can be a side effect of aspirin, it’s usually not severe enough to warrant reporting to the provider unless it’s persistent or severe.
Choice B rationale:
Rhinitis, or inflammation of the mucous membrane of the nose, can be an allergic reaction to aspirin and should be reported to the provider.
Choice C rationale:
Hematocrit (Hct) level of 43% is within the normal range for both men (38.8–50.0 %) and women (34.9–44.5 %), so this finding would not need to be reported.
Choice D rationale:
A blood pressure reading of 120/70 mm Hg is within the normal range and would not need to be reported.
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