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 B

Explanation

A. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: While verifying a DNR order is important, not all advance directives are represented by a bracelet. This action alone does not clarify the client’s wishes or the specifics of the living will.

B. Seek clarification of the type of advance directive the client has: Living wills and other advance directives vary in scope and specificity. Confirming the type of directive ensures that care aligns with the client’s legally documented wishes and guides future interventions appropriately.

C. Explain that living wills cannot be followed by emergency personnel: Emergency personnel can follow advance directives if they are clearly documented and accessible. Saying they cannot be followed is inaccurate and may create mistrust with the family.

D. Schedule a client and family conference to review the plan of care: A conference may be helpful later for education and care planning, but it does not address the immediate need to clarify the client’s specific directives after an emergency intervention.

A. Plumb line test indicates fetal position curvature. B. Ortolani maneuver causing a click at the hip joint. C. Babinski test that reveals fanning out of toes. D. Moro test precipitating a startle response.

Correct Answer is B

Explanation

A. Plumb line test indicates fetal position curvature: This assessment is used to evaluate spinal alignment and posture, not hip integrity. It does not explain asymmetrical buttocks in a newborn.

B. Ortolani maneuver causing a click at the hip joint: A positive Ortolani sign (a “click” or “clunk”) indicates hip dysplasia or subluxation. This finding is significant and should be reported to the healthcare provider for further evaluation and management.

C. Babinski test that reveals fanning out of toes: The Babinski reflex is normal in newborns and does not indicate musculoskeletal abnormality. It is unrelated to asymmetrical buttocks.

D. Moro test precipitating a startle response: The Moro reflex is a normal newborn response and does not indicate hip instability or asymmetry in the buttocks.

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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

Correct Answer is B

Explanation

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