# A 78-year-old opioid-naive client is admitted for a hip fracture and an order is received for morphine PCA: demand dose 1 mg, lockout 8 minutes, plus a continuous basal infusion of 1 mg per hour. Which is the priority nursing action before initiating? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=375174&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## Question A 78-year-old opioid-naive client is admitted for a hip fracture and an order is received for morphine PCA: demand dose 1 mg, lockout 8 minutes, plus a continuous basal infusion of 1 mg per hour. Which is the priority nursing action before initiating? ## Option 1. Increase the demand dose to 2 mg while keeping the basal infusion at 1 mg/hr; a basal rate ensures continuous pain relief, especially during sleep, and a higher demand dose adapts the PCA for the higher opioid requirements of an opioid-naive elderly patient. This approach is commonly endorsed for postoperative patients to prevent gaps in analgesia and reduce the need for nurse-administered boluses. 2. Initiate the PCA as prescribed because the basal infusion provides a steady plasma concentration of morphine, which is essential for managing severe postoperative pain in an elderly hip fracture patient. It ensures continuous analgesia without frequent patient effort, and the lockout prevents overdosing; this standard approach is recommended by acute pain services for opioid-naive patients. 3. Hold initiation and contact the prescriber to clarify; ISMP and Joint Commission caution against routine basal infusions in opioid-naive adults because the basal bypasses the patient self-protection mechanism and increases respiratory depression risk, especially in the elderly; recommend demand-only dosing at the start with reassessment, multimodal analgesia, and continuous monitoring. **✔ Correct answer** 4. Commence the PCA as ordered, but program the monitor to check respiratory rate every 30 minutes and keep naloxone at the bedside; this way, if respiratory depression occurs, it can be reversed promptly while still providing adequate pain control. This strategy is often used in postoperative units to safely manage PCA basal infusions in older adults and is considered a standard safety measure. **Correct answer: 3** ## Explanation Patient-controlled analgesia for opioid-naive adults follows the safety principle that the patient is the only one who should self-administer; sedation prevents further button presses and is the first-line guard against overdose. A continuous basal infusion bypasses this guard because dose continues regardless of patient state. ISMP and Joint Commission both caution against routine basal infusions in opioid-naive adults; basal infusions are reserved for patients with documented opioid tolerance, severe cancer pain, or end-of-life care, with extra monitoring and prescribed plans. Older adults are at particularly high risk because of altered pharmacokinetics, reduced renal/hepatic clearance, polypharmacy, and existing respiratory and cognitive vulnerabilities. Standard initiation in this patient: (1) hold the basal portion, contact the prescriber to clarify and request demand-only dosing initially with frequent reassessment; (2) ensure multimodal analgesia (acetaminophen scheduled, regional anesthesia or nerve block when available, ice/ice packs, position and physical therapy); (3) continuous SpO2 with capnography for high-risk patients; (4) frequent POSS, RR, and pain reassessment with two-nurse double check; (5) document and educate the patient and family. Starting as ordered, turning off oximetry, or doubling the demand dose are all unsafe; the basal must be addressed through the prescriber. ## In-depth explanation Basal infusion plus opioid-naive elderly is the textbook overdose recipe. Hold and clarify before starting; safer plan is demand-only with multimodal and capnography. ## Related questions - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=en) - [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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