When evaluating the effects of PCA, the nurse notes that the patient is sedated and is difficult to arouse. What step should the nurse take next?
a. Insert an airway.
b. Turn patient to the side.
c. Stop the PCA.
d. Expect this as a patient outcome of the therapy.
C
If the patient is sedated and is not readily arousable, stop the PCA. As long as the patient has spontaneous respirations, instruct him or her to take deep breaths. Apply oxygen at 2 L via nasal cannula. Elevate the head of the bed 30 degrees, unless contraindicated, to facilitate respirations. Heavy sedation is not an expected outcome of PCA therapy. Evaluate for the presence of analgesic side effects. Maintain a slightly drowsy, easily aroused patient.
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