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 B

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: The lockout mechanism is the most critical safety feature of a PCA pump. It prevents the client from administering a second dose of medication before the first dose has had time to take effect. By strictly limiting the frequency of doses (e.g., a 6-to-10-minute lockout period), the pump prevents accidental overdose and toxicity. While all the listed options are part of the nursing process, ensuring the mechanical safety of the high-alert medication delivery system is the priority during the initiation phase.

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: The nurse must ensure the client can communicate their pain level to evaluate the effectiveness of the therapy. However, this is a baseline assessment that should ideally occur before the initiation of the pump. It does not carry the same immediate safety weight as securing the pump's lockout mechanism.

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Correct Answer is A

Explanation

A. Remind the client to keep his appointments to have his cholesterol level checked: Ezetimibe works by reducing absorption of cholesterol in the intestines, which lowers serum lipid levels. The most direct way to evaluate effectiveness is through laboratory testing of cholesterol levels at scheduled follow-up appointments.

B. Assess the elasticity of the client's skin at the next scheduled clinic appointment: Skin elasticity is not affected by cholesterol-lowering therapy and does not provide meaningful information about the effectiveness of ezetimibe.

C. Teach the client to weigh himself weekly and keep a log of the measurements: Weight monitoring is more relevant for managing conditions like heart failure or obesity. Ezetimibe’s primary effect is on lipid levels, not weight change.

D. Encourage the client to keep a diary of his food intake until his next visit to the clinic: While dietary tracking supports lifestyle management, it does not directly measure the pharmacologic effectiveness of ezetimibe. Laboratory results remain the standard for evaluation.

A. Prone. B. Sims. C. Supine. D. Fowlers.

Correct Answer is C

Explanation

A. Prone: Prone positioning limits assessment of spinal curvature, extremity alignment, and body symmetry because the client is lying on the abdomen, which can obscure certain postural deviations.

B. Sims: Sims position is primarily used for rectal or vaginal procedures and does not provide a full view of overall body alignment, making it less ideal for assessment purposes.

C. Supine: Supine position allows the client to lie flat on the back with the body fully supported. This position provides the best view of the head, neck, spine, shoulders, hips, and extremities for a comprehensive assessment of body alignment.

D. Fowlers: Fowlers position elevates the head and torso, which may alter natural spinal alignment and obscure an accurate assessment of posture and symmetry compared with a flat, supine position.

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

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