The nurse assesses the patient who is 2 days postoperative to determine the need for continuing patient-controlled analgesia (PCA). Which information should the nurse use to decide that the patient is ready for oral administration of analgesia?

Question

a. Patient is hypoventilating.
b. Pain level ranges from 2 to 4.
c. Sedation level is consistent.
d. BP is 168/96, HR 110, RR 26.

Answer 1

B
The nurse uses the patient's pain level ranging from 2 to 4 to help determine that oral analgesia is suitable for him or her because the patient's pain level is consistently below the mid-range on the pain scale. PCA is more suitable for moderate-to-severe pain, and oral analgesia is more suitable for low-to-moderate pain. Hypoventilation is an adverse effect of opioid analgesia, regardless of the administration method. Hypoventilation indicates that the patient potentially receives an ex-cessive dose of opioid or that the dose remains inadequate and the patient is hypoventilating to prevent pain. A consistent sedation level is vague and provides little information about patient status. It can indicate a serious neurological impairment or excessive dosing and warrants further investigation. An elevated blood pressure, heart rate, and respiratory rate are nonverbal indicators of pain and indicate inadequate pain relief. However, these readings alone give no indication of the best route for administration of analgesia.