# A nurse is monitoring a postoperative client receiving morphine via patient-controlled analgesia (PCA) after total knee arthroplasty. Which interventions reflect safe PCA management? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=364913&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question A nurse is monitoring a postoperative client receiving morphine via patient-controlled analgesia (PCA) after total knee arthroplasty. Which interventions reflect safe PCA management? Select all that apply. 1 Allow only the client to press the demand button and instruct family not to push it for the client 2 Increase the basal infusion rate without notifying the provider if pain is uncontrolled 3 Monitor sedation level (Pasero scale), respiratory rate, SpO2, and pain at scheduled intervals 4 Independent two-RN check of pump settings against the order at every shift change 5 Have naloxone and a bag-valve-mask immediately available at the bedside ## Explanation PCA is a high-alert medication delivery system. Standard safe practice includes independent two-RN verification at shift change, PCA-by-proxy prevention (only the client presses), structured sedation and respiratory monitoring (Pasero scale, RR, SpO2), and immediate availability of naloxone reversal plus airway equipment. Increasing basal rate without provider order is outside the nurse scope and a major safety violation. ## In-depth explanation Clinical Judgment PCA safety pillars: independent double-check, PCA-by-proxy prevention, structured monitoring, naloxone ready. The basal rate is the highest-risk parameter; only providers may change it. Family-administered PCA-by-proxy has caused fatal respiratory depression and is prohibited unless explicitly ordered as Authorized Agent Controlled Analgesia (AACA) with training. Memory Tip PCA = Patient ONLY. Naloxone + RR + Pasero ready. KR vs US ISMP and Korean Hospital Patient Safety Act both classify PCA opioids as high-alert. Both jurisdictions require independent double-check at shift change and prohibit unauthorized family or staff dose delivery. Pasero Opioid-Induced Sedation Scale is widely used in Korean tertiary hospitals. ## Clinical scenario Clinical Practice Guide ISMP + ASPMN PCA safety: - Independent two-RN check at start, shift change, syringe change, dose change - PCA-by-proxy prevention: only the client may press; document teaching to family - Sedation scale (Pasero) q1h x 4, then q4h: S=sleep, 1=awake, 2=slightly drowsy, 3=frequently drowsy (HOLD), 4=somnolent (HOLD + naloxone) - Respiratory rate and SpO2 on the same schedule - Naloxone, bag-valve-mask, oxygen at bedside - ETCO2 capnography for opioid-naive or high-risk clients - Track demand vs delivered ratio — high attempts with few delivered = inadequate analgesia Caution Naloxone dosing for over-sedation: 0.04 mg IV q2min titrated to RR >10 and arousable. Larger doses can precipitate severe pain rebound and pulmonary edema. Stop the PCA infusion until reassessed. ## Key concepts - **PCA (Patient-Controlled Analgesia)** — Programmable IV pump that allows the client to self-administer pre-set demand doses with safety lockout. Optional basal infusion. Common opioids: morphine, hydromorphone, fentanyl. Reduces total opioid use and improves pain control versus PRN regimens. - **PCA by proxy** — Family member or staff pushing the demand button on behalf of an unconscious or sedated client. Has caused fatal respiratory depression. Strictly prohibited unless ordered as Authorized Agent Controlled Analgesia with documented teaching and competence. - **Pasero Opioid-Induced Sedation Scale** — Bedside scale assessing opioid-induced sedation: S=sleep easily aroused, 1=awake/alert, 2=slightly drowsy, 3=frequently drowsy/arousable but drifts, 4=somnolent/minimal response. 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