Which is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PСА) pump?

Assess the abdomen for bowel sounds.

Initiate the dosage lockout mechanism on the PCA pump.

Instruct the client to use the medication before the pain becomes severe.

Assess the client's ability to use a numeric pain scale.

Answer and Explanation

The Correct Answer is D

A. Assess the abdomen for bowel sounds: Monitoring bowel sounds is important during opioid therapy because morphine can cause constipation. However, this assessment does not take priority when initiating PCA therapy, as it does not immediately affect safe administration or pain control.

B. Initiate the dosage lockout mechanism on the PCA pump: While critical for safety, it is part of pump setup and not the first priority; assessing the client’s understanding of pain reporting comes first to ensure safe and effective use.

C. Instruct the client to use the medication before the pain becomes severe: Teaching about preemptive use improves pain control and prevents breakthrough pain, but this instruction is most effective after determining that the client can understand and use the PCA system appropriately.

D. Assess the client's ability to use a numeric pain scale: Evaluating the client’s understanding of a pain scale ensures they can accurately report pain levels and self-administer the correct dose using the PCA. This assessment is the priority because safe and effective pain management depends on the client’s ability to communicate pain accurately.

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Correct Answer is D

Explanation

A. "You should not worry about the growth tables. They are only averages for children.": Growth charts are standardized tools used to compare a child’s development with expected norms. Dismissing the concern overlooks an important clinical sign and fails to address the parent’s valid question.

B. "Haven't you been feeding according to recommended daily allowances for children?": This response places blame on the parent and does not acknowledge the child’s medical condition. It may also create unnecessary guilt rather than offering supportive education.

C. "Does your child seem mentally slower than his peers also?": Asking about developmental delay in this way is inappropriate and insensitive. It shifts the focus to cognitive ability rather than addressing the physical growth concern directly tied to the child’s condition.

D. "The smaller size is probably due to the heart disease.": Children with congenital heart defects often experience poor growth because of increased metabolic demands and reduced energy available for growth. This response gives the parent a clear, accurate explanation while validating the concern.

A. Verbal reassurance. B. Simultaneous injections. C. Supine positioning. D. Physical soothing.

Correct Answer is B

Explanation

A. Verbal reassurance: While helpful for reducing anxiety, verbal reassurance alone does not significantly shorten the duration of pain associated with multiple injections.

B. Simultaneous injections: Administering multiple vaccines at the same time in different sites reduces the overall number of needle sticks and the total duration of pain the toddler experiences, making this the most effective strategy.

C. Supine positioning: Proper positioning can improve safety and comfort during injections but does not directly decrease the duration of pain from the procedure.

D. Physical soothing: Holding or comforting the toddler helps reduce distress and anxiety, but it does not shorten the actual time the pain stimulus occurs.

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Which is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PСА) pump?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Correct Answer is B

Explanation

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