RN Nursing · Opioid Analgesic Medications · Practice question
A nurse is preparing to initiate PCA morphine for a 59-year-old postoperative client following abdominal surgery. Which nursing precautions must the nurse implement? Select all that apply.
Nurse's Notes
The client's spouse says, "I'll make sure to press the button if my husband falls asleep so he doesn't wake up in pain."
The nurse reviews the client's orders:
PCA morphine
Demand dose: 1 mg
Lockout interval: 8 minutes
Continuous pulse oximetry ordered
Sedation scale assessments q2 hour
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Set the PCA so a family member can activate it when needed.
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✓
Ensure that only the client presses the PCA button.
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✓
Monitor respiratory rate and sedation level frequently
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Tell the spouse to press the button whenever pain is reported.
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✓
Educate the client to press the button before the pain becomes severe.
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✓
Administer supplemental oxygen if respiratory rate drops below 10/min
Answer & explanation
Correct: Ensure that only the client presses the PCA button. · Monitor respiratory rate and sedation level frequently · Educate the client to press the button before the pain becomes severe. · Administer supplemental oxygen if respiratory rate drops below 10/min
Several precautions are essential when initiating PCA morphine for a postoperative patient. First, only the client should press the PCA button — this is a foundational safety principle known as PCA by proxy prevention. When family members activate the PCA, the built-in safety mechanism is bypassed: if the client is oversedated or sleeping, they would not press the button themselves, thereby self-limiting their dose. The spouse's stated intention to press the button while the client sleeps must be directly addressed and prevented through education. Monitoring respiratory rate and sedation level frequently is mandatory because opioids cause dose-dependent respiratory depression; the ordered continuous pulse oximetry and q2-hour sedation scale assessments support this. Educating the client to press the button before pain becomes severe is correct because it is more effective to prevent pain escalation than to treat established severe pain, and it ensures the client uses the device appropriately. Administering supplemental oxygen if respiratory rate drops below 10/min is a valid safety intervention for opioid-induced respiratory depression. Setting the PCA for family activation or telling the spouse to press the button whenever pain is reported are both incorrect and unsafe — they represent PCA by proxy, which can result in fatal respiratory depression.
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