A nurse is caring for a client who is 12 hours postoperative following an abdominal surgery and is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump. Which of the following nursing actions are appropriate for the safe administration and monitoring of this therapy? (Select all that apply.)
- Require an independent double-check of the pump settings with a second registered nurse during shift handoff.Cevap
- BDelegate the routine assessment of the client's pain score and respiratory effort to the unlicensed assistive personnel (UAP).
- CAdminister a prescribed intravenous antiemetic through the PCA Y-site without verifying continuous fluid compatibility.
- Monitor the client's sedation level and respiratory rate at frequent, regular intervals per facility protocol.Cevap
- EMaintain the client in a flat, supine position to enhance the continuous gravitational flow of the intravenous fluids.
- Ensure that an opioid antagonist and emergency airway equipment are immediately accessible on the unit.Cevap
Cevap
The appropriate actions for a client receiving intravenous PCA therapy include requiring an independent double-check of pump settings with a second registered nurse, monitoring the sedation and respiratory status frequently, and ensuring emergency airway equipment and an opioid antagonist are accessible.
Safe PCA administration requires strict adherence to medication safety protocols, including independent double-checks by two nurses to prevent programming errors. Additionally, because opioid analgesics suppress the central nervous system, vigilant monitoring of the client's respiratory rate and sedation level is essential. Finally, emergency preparedness is mandatory; an opioid antagonist (naloxone) and airway equipment must be immediately accessible to reverse severe respiratory depression if it occurs.
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Safe administration and monitoring of patient-controlled analgesia (PCA)