# The nurse enters a postoperative client's room and finds the spouse pressing the PCA button repeatedly while the client sleeps. The client's POSS is 3 (frequently drowsy) and respiratory rate is 9 per minute. Which is the priority nursing action?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375172&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

The nurse enters a postoperative client's room and finds the spouse pressing the PCA button repeatedly while the client sleeps. The client's POSS is 3 (frequently drowsy) and respiratory rate is 9 per minute. Which is the priority nursing action?

## Option

1. Document the event in the chart and continue the PCA as ordered.
2. Adjust the lockout to allow the spouse to keep pressing.
3. Praise the spouse for advocating for the client's comfort.
4. Stop the spouse immediately, stop the PCA, stimulate and oxygenate the client, prepare to administer naloxone if respiratory depression progresses, notify the prescriber and rapid response, complete an event report and re-educate that PCA-by-proxy is a sentinel event prohibited by Joint Commission and ISMP. **✔ Correct answer**

**Correct answer: 4**

## Explanation

PCA-by-proxy refers to anyone other than the patient pressing the button — family, visitors, well-meaning friends, or unauthorized staff (so-called nurse-controlled analgesia is different and only allowed under specific protocols for patients unable to participate, such as pediatrics or end-of-life care, with explicit orders). PCA-by-proxy is a documented sentinel event by the Joint Commission, with reported deaths from cumulative opioid overdose. Recognized warning signs in the example: POSS 3 with RR 9 indicates impending opioid-induced respiratory depression. Priority actions: (1) stop the proxy immediately and explain the danger compassionately, (2) stop the PCA infusion to halt cumulative dosing, (3) stimulate the patient, apply oxygen, position to maintain airway, monitor RR, SpO2, and POSS continuously, (4) prepare naloxone 0.04 to 0.4 mg IV titrated if respiratory depression worsens (RR less than 8, unresponsive, SpO2 dropping); call rapid response, (5) notify prescriber for orders and consider switching to non-PCA modality, (6) complete a hospital event report; education for spouse, patient, and posted signs is part of follow-up. Praising, adjusting lockout, or only documenting are unsafe.

## In-depth explanation

PCA-by-proxy is a sentinel event. Stop the proxy, stop the PCA, treat the airway, and prepare naloxone — not document and continue.

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