# Stage 2 — Analyze cues. Complete the four safety statements that guide the response to the PCA, potassium, and heparin findings. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372857&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question Stage 2 — Analyze cues. Complete the four safety statements that guide the response to the PCA, potassium, and heparin findings. The PCA demand button should be activated by ::선택::any family member who sees a pain cuethe awake patient who can understand and physically activate itthe nurse whenever the patient is asleep. When a central-line-only 400 mEq/L potassium infusion causes burning at a peripheral site, the nurse should first ::선택::increase the rate so the vein is exposed for less timemove the unchanged bag immediately to another peripheral veinstop the infusion and assess and manage the site under policy. A slightly out-of-range aPTT during unfractionated heparin therapy is managed by ::선택::verifying the result and infusion, assessing bleeding, and applying the institution-specific nomogramusing the same fixed reduction in every hospitalraising the rate to protect the new coronary stent. If opioid-related respiratory depression persists despite initial support, the nurse should prepare to give ::선택::a full vial rapidly in every postoperative patientprotocol-directed titrated naloxone while supporting ventilationadditional morphine to improve respiratory comfort. ## Explanation Four safety conclusions The PCA button is activated only by an awake, capable patient. A painful peripheral site receiving a 400 mEq/L potassium solution requires the nurse to stop the infusion and assess and manage the site, then obtain a safer plan. Heparin is managed by verifying the result and infusion, assessing bleeding, and applying the institution-specific nomogram. Persistent opioid-related respiratory depression is treated with ventilation support and protocol-directed titrated naloxone when indicated. ## In-depth explanation PCA safety A pump limit does not make proxy activation safe. The awake patient's ability to press is part of the safety design, so the button remains under patient control and staff reassess an uncontrolled pain plan. Potassium site safety The 40 mEq/100 mL preparation equals 400 mEq/L. With a central-only label and peripheral burning, stop first, assess for infiltration or phlebitis, follow site policy, and ask pharmacy and the prescriber to reassess the remaining dose and route. Heparin is protocol-specific Verify the aPTT timing and sampling, pump and order, bleeding findings, and exact nomogram instruction. Do not invent a fixed change from a generic range or increase anticoagulation simply because a stent was placed. Reverse to adequate ventilation When stimulation and airway or breathing support are insufficient, use naloxone according to the emergency or postoperative protocol and titrate to adequate ventilation and alertness. Continue monitoring because repeat doses can be necessary. ## Clinical scenario Scenario (Stage 2 — Analyze cues) The nurse must translate the respiratory, infusion-site, and coagulation data into medication-specific safety rules. Clinical judgment target Choose patient-control, stop-and-assess, protocol-based titration, and ventilation-focused rescue principles. ## Key concepts - **Patient-only PCA activation** — The awake, capable patient activates each demand dose; family or unauthorized caregiver activation can continue opioid delivery despite sedation. - **Concentration-route match** — Verification that an infusion's final concentration is appropriate for the vascular access and institutional policy before administration or restart. - **Heparin nomogram** — An institution-specific protocol that maps a valid coagulation result and clinical assessment to the required hold, rate change, and repeat testing interval. ## Related questions - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. 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Always follow current clinical guidelines and your institution’s protocols._