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Difficulty: MediumPharmacological and Parenteral Therapies

A nurse is preparing to care for a postoperative client who will receive intravenous morphine sulfate via a patient-controlled analgesia (PCA) pump. Which of the following nursing actions are appropriate to ensure the safe administration of this parenteral therapy? (Select all that apply.)

  1. Verifying the PCA prescription and pump settings independently with a second registered nurse.Answer
  2. B
    Instructing family members to press the medication delivery button if the client grimaces while sleeping.
  3. Connecting the PCA tubing to a primary intravenous line with a continuous infusion of a compatible maintenance fluid.Answer
  4. Monitoring the client's respiratory rate, oxygen saturation, and sedation scale score at regular intervals.Answer
  5. E
    Disabling the pump's occlusion alarm overnight to prevent waking the client if the tubing becomes temporarily kinked.

Answer

The appropriate actions for safe PCA administration are verifying the pump settings with a second registered nurse, connecting the PCA tubing to a running primary intravenous fluid line, and regularly monitoring the client's respiratory and sedation status.
Safe administration of a PCA involves verifying the settings with a second registered nurse to prevent programming errors, attaching the line to a continuous compatible carrier fluid to ensure the medication reaches the client and keeps the vein open, and strictly monitoring respiratory and sedation status to detect early signs of opioid toxicity.

Step-by-Step Solution

1
Identify the high-risk nature of intravenous opioid administration via a patient-controlled analgesia (PCA) pump.
Recognize that strict safety protocols, including dual verification and continuous clinical monitoring, are mandatory.
Opioids cause central nervous system depression, and administration errors can lead to fatal respiratory arrest.
2
Evaluate each proposed nursing action against established parenteral medication safety standards.
Determine that independent verification, using a carrier fluid, and conducting regular respiratory and sedation assessments are correct safety measures.
These actions prevent programming errors, ensure reliable medication delivery into the vein, and allow for the early detection of adverse effects.
3
Identify the unsafe practices among the options to eliminate them.
Identify that allowing family members to press the button (PCA by proxy) and disabling pump alarms are dangerous and contraindicated.
PCA by proxy bypasses the built-in safety of the client self-regulating doses based on their sedation level, while disabling alarms removes critical alerts for intravenous line failure.

Key Concept

Safe Patient-Controlled Analgesia (PCA) Administration
Estimated Time:1m 30s
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Topics

Pharmacological and Parenteral Therapies

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