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 A
Explanation
Choice A rationale:
A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.
Choice B rationale:
Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.
Choice C rationale:
Constipation is a common side effect of morphine and can be managed with laxatives and diet.
Choice D rationale:
Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.
Correct Answer is C
Explanation
Choice A rationale:
The first dose of the varicella vaccine is usually given when the child is between 12 to 15 months old, not after 3 years.
Choice B rationale:
Aspirin should not be given to children due to the risk of Reye’s syndrome. This syndrome is a rare but serious condition that causes swelling in the liver and brain.
Choice C rationale:
The varicella vaccine should be avoided in children who have leukemia or any other condition that weakens the immune system.
Choice D rationale:
The varicella vaccine is not contraindicated for children who are allergic to eggs. It’s some other vaccines like influenza that have this restriction.
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