A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?
Explanation & Rationale
A. "Instruct the client's visitors not to operate the PCA pump.” Only the client should press the PCA button to self-administer medication. Allowing visitors or family members to press the button ("PCA by proxy") increases the risk of over-sedation, respiratory depression, and opioid toxicity. The nurse should reinforce to visitors that only the client should control medication delivery based on their own pain level. B. "Check the client's pain level every 8 hours." Pain assessment should be performed more frequently than every 8 hours when a client is receiving morphine PCA. Pain, sedation level, and respiratory status should be monitored every 1–2 hours initially and then at regular intervals as determined by hospital protocol to ensure effective pain management and prevent complications such as respiratory depression. C. "Diarrhea is an adverse effect of morphine PCA." Morphine is an opioid analgesic that commonly causes constipation, not diarrhea. Opioids slow gastric motility, which can lead to delayed bowel movements, bloating, and discomfort. Clients on long-term opioid therapy often require stool softeners or laxatives to prevent opioid-induced constipation. D. "Using morphine PCA increases the client's risk of toxicity." PCA pumps are designed with preset dose limits and lockout intervals to prevent overdose. While there is a risk of opioid toxicity if the system is misused (e.g., PCA by proxy or improper settings), PCA is actually safer than traditional opioid administration methods because it allows for precise dosing and patient-controlled pain management. Proper monitoring helps prevent complications.