# A nurse is caring for an adult client after major abdominal surgery who is using an opioid patient-controlled analgesia (PCA) pump. Which actions promote safe PCA use? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368266&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is caring for an adult client after major abdominal surgery who is using an opioid patient-controlled analgesia (PCA) pump. Which actions promote safe PCA use? Select all that apply.

1

Keep naloxone readily accessible per facility protocol and assess risk factors for opioid-induced respiratory depression

2

Monitor respiratory rate, sedation with a validated scale, and oxygenation at prescribed intervals, and hold the opioid and notify the provider for severe sedation or respiratory depression

3

Teach family members to press the PCA button while the client sleeps when they observe grimacing or restlessness

4

Have one nurse verify PCA programming and concentration, relying only on the pump's safety software without following the facility's independent-check policy

5

Teach that the client alone presses the demand button, and explain the lockout interval and prescribed dose limit

6

Increase the basal infusion independently when pain persists, without obtaining a provider order

## Explanation

Only the client presses the demand button; sedation that prevents button use is an important safety brake (Choice 5). PCA by proxy defeats that safeguard (Choice 3). Monitor sedation, respiration, and oxygenation according to risk and protocol, holding medication and escalating for respiratory depression (Choice 2). Keep naloxone accessible and assess risk factors (Choice 1). Basal-rate changes require an order (Choice 6). Follow facility policy for independent verification of the high-alert opioid, concentration, and pump settings rather than relying only on software or a single unchecked setup (Choice 4).

## In-depth explanation

PCA Core Safety Principle
ONLY the client presses the demand button. If sedation reaches a level where the client cannot press, the system stops itself — built-in protection.

PCA by Proxy = NEVER
- Family/visitor pressing the button defeats the safety mechanism
- Leading cause of fatal opioid-induced respiratory depression on PCA
- Educate family and place a "PCA by proxy: Do Not Press" sign at bedside

Monitoring
1. Respiratory rate q1-2h initially
2. Sedation level (POSS — Pasero Opioid-induced Sedation Scale)
3. SpO2 continuous if high risk; capnography preferred
4. Hold opioid if RR <8/min or POSS 3-4 (frequent drowsiness or unarousable)
5. Naloxone readily available

High-Alert Medication Safeguards
- Two-RN independent verification: pump settings, drug, concentration, dose, lockout — at start of shift, bag change, rate change
- Smart pump with drug library
- Document programming

Risk Factors for Respiratory Depression
Older age, opioid-naive, OSA, BMI >30, concurrent CNS depressants, renal/hepatic impairment, post-major-surgery first 24 hr

Memory Tip
"Only-the-Client; Watch RR & Sedation; Two-RN check; Naloxone close"

## Clinical scenario

Scenario
Adult client, post major abdominal surgery, on opioid PCA pump. Family is present; client may be opioid-naive.

Safe PCA Care Bundle
1. Only client presses; family education + bedside sign
2. Two-RN independent verification of pump program at start, bag/rate change
3. RR + sedation (POSS) + SpO2 monitoring
4. Hold + notify: RR <8/min, deepening sedation
5. Naloxone readily available
6. Risk factor assessment

Avoid
- PCA by proxy
- Independent basal rate increase by nurse
- Single-RN verification of opioid program

## Key concepts

- **PCA Pump (Patient-Controlled Analgesia)** — Programmable infusion pump that allows the client to self-administer a preset bolus dose of an opioid (commonly morphine, hydromorphone, fentanyl) within prescribed limits. Components: demand dose, lockout interval (5-10 min typical), 1-hour or 4-hour dose limit, optional basal continuous rate. Safety relies on the principle that only the client presses; when sedation impairs ability to press, dosing pauses.
- **PCA by Proxy (Safety Hazard)** — Anyone other than the client (family member, visitor, or staff member acting at the request of the family) pressing the demand button. Defeats the built-in sedation-driven safety mechanism and is a leading cause of fatal opioid-induced respiratory depression on PCA. Strictly prohibited; nurses must teach the family explicitly and post a warning sign at the bedside. Authorized agent-controlled analgesia (AACA) programs in pediatrics or end-of-life care are a separate, formally authorized, and closely monitored exception.
- **Opioid-Induced Respiratory Depression Monitoring** — Use a validated sedation scale (e.g., Pasero Opioid-induced Sedation Scale — POSS: 1=awake/alert, 2=slightly drowsy/easy to arouse, 3=frequently drowsy/arousable but drifts off mid-conversation, 4=somnolent/minimal/no response). Hold opioid and notify provider for POSS 3-4 or RR <8/min. Risk factors: older age, opioid-naive, OSA, BMI >30, concurrent benzodiazepines or other CNS depressants, renal/hepatic impairment, post-major-surgery first 24 hours. Continuous capnography is the most sensitive monitor and is preferred for high-risk clients.

## Related questions

- [A nurse on a medical-surgical unit reviews the morning labs for a 67-year-old male client …](https://mymerci.kr/pages/nclex_q.php?qn_id=361711&lang=en)
- [A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following ton…](https://mymerci.kr/pages/nclex_q.php?qn_id=361812&lang=en)
- [A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit…](https://mymerci.kr/pages/nclex_q.php?qn_id=361898&lang=en)
- [A 72-year-old male client is receiving a continuous IV heparin infusion for a left lower-e…](https://mymerci.kr/pages/nclex_q.php?qn_id=362064&lang=en)
- [A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=363990&lang=en)
- [A nurse is teaching a 65-year-old client recovering from open upper abdominal surgery how …](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=en)
- [A nurse is conducting morning rounds on adult medical-surgical clients. Which clients shou…](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=en)
- [A nurse is administering a unit of packed red blood cells to a client. Twenty minutes afte…](https://mymerci.kr/pages/nclex_q.php?qn_id=364947&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=368266&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=368266&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=368266&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=368266&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=368266&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._