This question tests PCA safety and monitoring when medication supply is depleted. The priority concern related to PCA is maintaining continuous pain control by promptly replacing empty cartridges. Initiating facility procedure to replace the PCA medication cartridge using appropriate double-checks addresses the highest priority PCA issue by ensuring safe resumption of therapy. Telling the client to press more frequently is ineffective with an empty cartridge; holding opioids risks uncontrolled pain; delegating pain scores delays resolution. The decision-making principle for PCA monitoring is to follow medication safety protocols, including independent double-checks for high-alert drugs like opioids. Inventory checks prevent interruptions. A transferable strategy for monitoring clients on PCA is to anticipate cartridge changes based on usage rates and prepare in advance to minimize pain flares.

This question tests PCA safety and monitoring regarding proper administration roles. The priority concern related to PCA is maintaining the patient-controlled aspect to prevent overdose. The nurse pressing the PCA button on a schedule for the client should be questioned because it bypasses safety features and risks oversedation. The client using the button when pain increases is correct; using repositioning and splinting with PCA is appropriate; assessing pain and sedation regularly is essential. The decision-making principle for PCA monitoring is to adhere to patient-only activation to ensure doses align with perceived pain. Ethical guidelines prohibit proxy dosing. A transferable strategy for monitoring clients on PCA is to educate staff and clients on PCA principles to reinforce safe, autonomous use.

This question tests PCA safety and monitoring for common opioid side effects. The priority concern related to PCA is gastrointestinal side effects like nausea and vomiting, which can lead to dehydration or aspiration. Nausea and vomiting after opioid PCA use indicate a complication of PCA therapy because they are frequent adverse effects requiring antiemetic intervention. A pain score of 4/10 is acceptable postoperatively; oxygen saturation of 97% on room air is normal; respiratory rate of 16/min is within range. The decision-making principle for PCA monitoring involves distinguishing between expected side effects and serious complications, addressing symptoms promptly. Multimodal approaches reduce reliance on opioids. A transferable strategy for monitoring clients on PCA is to preemptively order antiemetics and monitor for GI symptoms to enhance comfort and adherence.

This question tests PCA safety and monitoring in a COPD client with new sedation symptoms. The priority concern related to PCA is hypoxia combined with excessive sleepiness suggesting opioid-induced depression. Oxygen saturation of 90% on 2 L/min with new excessive sleepiness requires immediate intervention because it indicates worsening respiratory status needing dose reduction or support. A pain score of 3/10 is adequate; heart rate of 74/min is normal; blood pressure of 116/68 mm Hg is stable. The decision-making principle for PCA monitoring is to interpret oxygen saturation in context with sedation and respiratory effort, especially in lung disease. Trends guide interventions. A transferable strategy for monitoring clients on PCA is to use continuous capnography in COPD clients to monitor CO2 levels alongside oxygenation.

This question tests PCA safety and monitoring for subtle signs of oversedation in high-risk clients. The priority concern related to PCA is intermittent arousal with low respiratory rate indicating progressive depression. Falling asleep mid-sentence with respiratory rate 9/min indicates a complication of PCA therapy because it reflects excessive sedation risking apnea in sleep apnea clients. A pain score of 2/10 is effective; blood pressure of 110/64 mm Hg is normal; heart rate of 66/min is within range. The decision-making principle for PCA monitoring is to intervene on early sedation signs before full unresponsiveness develops. Sedation scales quantify risk. A transferable strategy for monitoring clients on PCA is to perform frequent arousal tests, such as verbal stimulation, to assess depth of sedation.

This question tests knowledge of PCA safety and monitoring in a postoperative client using intravenous opioids. The priority concern with PCA is opioid-induced respiratory depression and excessive sedation, particularly in clients with risk factors like obesity. The assessment finding of increasing difficulty awakening the client combined with an oxygen saturation of 91% and respiratory rate of 10/min requires immediate intervention because it indicates potential opioid overdose and compromised airway, necessitating actions like stopping the PCA and administering naloxone. A pain score of 2/10 is expected and indicates effective pain control, a heart rate of 68/min is within normal limits for a resting adult, and a blood pressure of 116/72 mm Hg is also normal and does not suggest instability. When monitoring PCA, nurses should prioritize assessing sedation levels and respiratory status over vital signs that are within normal ranges. Decision-making involves using tools like the Pasero Opioid-Induced Sedation Scale to evaluate arousal and intervening promptly if sedation increases. A transferable strategy for monitoring clients on PCA is to perform frequent assessments of respiratory rate, oxygen saturation, and level of consciousness, especially in the first 24 hours postoperatively, to prevent adverse events.

This question tests PCA safety and monitoring in a high-risk client with obstructive sleep apnea. The priority concern related to PCA is the increased risk of respiratory depression due to somnolence and apnea. Ensuring continuous oxygen saturation monitoring and frequent sedation/respiratory assessments addresses the highest priority PCA issue by enabling early detection of hypoxia or oversedation. Encouraging button presses is standard but not priority over monitoring; requesting a basal infusion increases risk in apnea; delegating ambulation does not address monitoring needs. The decision-making principle for PCA monitoring is to heighten surveillance in clients with sleep disorders using tools like continuous oximetry. Risk stratification guides frequency of assessments. A transferable strategy for monitoring clients on PCA is to incorporate home CPAP use postoperatively and monitor for apnea episodes during sleep.

This question tests PCA safety and monitoring for critical vital sign changes. The priority concern related to PCA is respiratory depression with altered consciousness in a cardiac client. Respiratory rate of 8/min with decreased level of consciousness requires immediate intervention because it signals potential arrest needing urgent reversal. A pain score of 3/10 is acceptable; heart rate of 60/min is normal; blood pressure of 118/72 mm Hg is stable. The decision-making principle for PCA monitoring is to prioritize respiratory assessments, intervening if rate falls below 10/min with sedation. ABC framework guides actions. A transferable strategy for monitoring clients on PCA is to set alarm parameters on monitors for low respiratory rates to prompt immediate checks.

This question tests PCA safety and monitoring in response to equipment alarms. The priority concern related to PCA is resolving occlusions to restore medication delivery and pain control. Assessing the IV site and tubing for kinks or infiltration and correcting the occlusion addresses the highest priority PCA issue by ensuring uninterrupted therapy. Increasing opioid concentration risks overdose; teaching to wait between presses ignores the alarm; delegating alarm silencing is unsafe without resolution. The decision-making principle for PCA monitoring is to treat alarms as indicators of potential failures requiring immediate nurse intervention. Systematic troubleshooting prevents complications like untreated pain. A transferable strategy for monitoring clients on PCA is to inspect infusion sites and tubing q4h or with alarms to maintain patency and efficacy.

This question tests PCA safety and monitoring, focusing on optimizing pain control for pulmonary hygiene in post-thoracotomy clients. The priority concern is ensuring adequate pain control to enable deep breathing and coughing, which are essential for preventing postoperative pulmonary complications. The correct answer (B) addresses the highest priority by assessing PCA usage patterns and client technique before requesting dose changes, as inadequate pain control during pulmonary hygiene activities increases complication risk. Option A (increasing oxygen) doesn't address the pain issue, option C (stopping PCA) is inappropriate as the respiratory rate is normal for COPD, and option D (delegating PCA education) requires RN assessment and teaching. The decision-making principle is that post-thoracotomy clients need optimal pain control to perform pulmonary hygiene, and PCA effectiveness depends on proper client technique. The transferable strategy is to assess PCA usage patterns and provide pre-emptive dosing education for activities like coughing and incentive spirometry in thoracic surgery clients.