A postoperative client that recently returned from surgery has a morphine PCA pump. The basal rate is ordered to be 1 mg/hour and the patient can have a 1-mg bolus every 15 minutes
When the nurse assesses the client, the nurse finds the client stuporous, hard to arouse, with a respira-tory rate of 6 breaths/minute. After successfully treating the client, which action by the nurse takes priority? The nurse should a. ask the physician to discontinue the PCA pump and revert to prn opioids for pain.
b. check the IV pump to ensure the basal rate is set correctly.
c. question the client about how he/she has been using the button on the pump.
d. request the physician order different basal and bolus rates.
B
The patient exhibited manifestations of opioid toxicity. The ordered dose was well within a safe range for a postoperative client. On a PCA pump, the demand feature has a lock-out device li-miting the amount of opioid the client can administer. This could have been set incorrectly, al-lowing the client to overdose him/herself; however, a sleepy postoperative client often cannot use the demand feature without reminders. This leaves the basal rate as the most likely source of error and the nurse should check to see that it was set correctly. Giving prn pain medications often results in undertreatment of pain and should not be used on a postoperative client. If the pump was set incorrectly, there is no need to adjust the rates. Questioning the client and re-educating him/her if needed are always appropriate, but it is not the priority since the pump most likely was set incorrectly.
You might also like to view...
Which of the following is a type of research with an ideological perspective? Select all that apply
A) Critical ethnography B) Symbolic interaction C) Participatory action research D) Feminist research
The nurse is instructing a patient about the symptoms of hyperparathyroidism. Which symptoms should the nurse include in this discussion?
Select all that apply. 1. abdominal pain 2. dysrhythmias 3. hypertension 4. diarrhea 5. reduced urine output
To ensure all inpatients receive adequate care, The Joint Commission specifies that nutrition screening be conducted at what time during hospital admission?
A) Immediately upon admission C) Within 24 hours after admission B) Within 12 hours after admission D) Within 36 hours after admission
The nurse is conducting a health history interview, and the patient asks the nurse what an advance directive is. Which response by the nurse is appropriate?
1) "Advance directives ensure end-of-life care is comfort measures only." 2) "Advance directives ensure healthcare wishes are carried out." 3) "Advance directives ensure acute illness will be treated aggressively." 4) "Advance directives ensure treatment will be withheld for life-threatening injury or illness."