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. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours: Intermittent collection is not used for a 24-hour urine test; continuous collection of all urine after the start time is required to accurately measure creatinine clearance.

B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle: This procedure is for a clean-catch or midstream urine specimen, not a 24-hour collection, and does not provide the total volume needed for creatinine clearance.

C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens: Catheterization is unnecessary for routine 24-hour urine collection and increases infection risk. The client can collect urine in a provided container.

D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: Discarding the first void establishes the start of the collection period, and collecting all urine for the next 24 hours ensures accurate measurement of creatinine clearance.

A. Notify the social worker the client is awake. B. Explain all procedures C. Increase the propofol infusion D. Consider extubating the client

Correct Answer is ["B","F","G","H"]

Explanation

A. Notify the social worker the client is awake: The social worker is already attempting to contact family. Awakening does not require immediate notification; the priority is client care and stabilization.

B. Explain all procedures: As the client becomes more alert, clear explanations reduce anxiety, promote cooperation, and support orientation, especially in the ICU environment.

C. Increase the propofol infusion: Increasing sedation without clinical indication may mask neurological changes and hinder assessment. Sedative adjustments should be based on prescribed parameters and provider orders.

D. Consider extubating the client: Extubation is only considered when specific respiratory and hemodynamic criteria are met. Waking up does not automatically mean the client is ready to be extubated.

E. Have the client sign consent forms for procedures already performed: Consent must be obtained prior to procedures. Once completed, retroactive consent is not valid or ethical.

F. Assess the client’s pain: Pain assessment is essential in postoperative and trauma patients, particularly once the client is able to communicate.

G. Determine the client’s decision-making ability: As the client becomes more awake, assessing cognitive status and ability to participate in care decisions is appropriate and supports autonomy.

H. Decrease the noise and light stimuli in the room as much as possible: Minimizing environmental stimuli helps reduce delirium risk, improves comfort, and promotes healing in critically ill patients.

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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

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Correct Answer is D

Explanation

Patient Data Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Correct Answer is ["B","F","G","H"]

Explanation

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