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Difficulty: HardAccident, Error, and Injury Prevention

A nurse enters the room of a 72-year-old client who is recovering from a total hip arthroplasty and is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump. The nurse observes the client's spouse pressing the PCA dosing button while the client appears deeply asleep. The spouse states, 'I am pressing the button every time the green light comes on so he doesn't wake up in severe pain.' Which action is the priority for the nurse to take to prevent a critical adverse event?

  1. A
    Explain to the spouse that 'PCA by proxy' can cause a fatal overdose and document the need for further education.
  2. B
    Delegate the unlicensed assistive personnel (UAP) to continuously monitor the client's oxygen saturation while the nurse notifies the healthcare provider.
  3. C
    Attribute the client's deep sleep to the normal physiological fatigue associated with major surgery in older adults and allow the client to rest.
  4. Intervene to stop the spouse from activating the device and immediately evaluate the client's airway and respiratory status.Answer

Answer

The nurse must immediately stop the spouse from pressing the button and assess the client's airway and respiratory status.
The correct action directly addresses the immediate physical threat. By stopping the spouse, the nurse prevents further medication delivery. By immediately evaluating the client's airway and respiratory status, the nurse applies the ABCs of prioritization to detect life-threatening opioid-induced respiratory depression, which requires immediate clinical intervention.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the primary safety threat.
The spouse is administering morphine to a deeply sleeping client ('PCA by proxy'), creating an immediate risk for severe opioid toxicity and respiratory arrest.
Recognizing the mechanism of injury (unauthorized opioid dosing) dictates the urgency and type of the required intervention.
2
Apply Maslow's Hierarchy of Needs and the ABCs (Airway, Breathing, Circulation) framework.
Physiological needs and airway/breathing take absolute precedence over psychosocial needs, teaching, or documentation.
A client who is deeply asleep while receiving excess opioids may have a compromised airway or respiratory depression, which is life-threatening.
3
Determine the most appropriate initial nursing action.
The nurse must halt the unsafe act and immediately assess the client's respiratory rate, depth, and oxygen saturation.
Direct clinical assessment by the registered nurse is mandatory to determine if emergency interventions (such as administering naloxone or bag-valve-mask ventilation) are required.

Key Concept

Patient-Controlled Analgesia (PCA) Safety and Prioritization
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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