# A nurse is replacing an empty PCA bag. The pump label is set to morphine 1 mg/mL. The new bag from pharmacy is labeled hydromorphone 0.2 mg/mL. The pump is about to be restarted. Which is the priority nursing action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=375175&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## Question A nurse is replacing an empty PCA bag. The pump label is set to morphine 1 mg/mL. The new bag from pharmacy is labeled hydromorphone 0.2 mg/mL. The pump is about to be restarted. Which is the priority nursing action? ## Option 1. Since hydromorphone is an opioid, just like morphine, restart the PCA pump with the hydromorphone bag but keep the same pump programming; the smart pump's drug library will detect the concentration by reading the barcode and adjust the dose parameters automatically; after the pump begins infusing, contact the pharmacy to confirm the switch and update the patient's medication administration record. 2. Hang the new hydromorphone bag and restart the PCA pump at the current rate; the lower concentration means the patient will actually receive a smaller dose, so there is no risk of overdose; after the first bolus is delivered, contact the pharmacy to discuss whether the settings need to be adjusted for the new drug and then update the medication administration record. 3. Stop and do not restart the pump until the discrepancy is resolved; verify the order, the medication name, the concentration, and the pump program with another licensed nurse using independent double check; reprogram the pump for hydromorphone 0.2 mg/mL with the new orders, scan and verify the bag against the order, document, and re-educate that any change in drug or concentration is a high-alert checkpoint. **✔ Correct answer** 4. Attach the new hydromorphone bag to the existing PCA cassette, prime the line with the new solution, and restart the pump without changing the settings or verifying the order; because both medications are opioids, the pump's safety software will limit the dose to a safe range; if the patient reports pain, then call the provider to adjust the order and document the medication substitution in the record. **Correct answer: 3** ## Explanation PCA programming errors are well-documented and frequently fatal in pediatric and adult settings. Two most common errors: (1) wrong drug entry — programming morphine when hydromorphone is in the bag, or vice versa, with up to 7-fold dose error; (2) wrong concentration — programming 1 mg/mL when the bag is 0.2 mg/mL or 5 mg/mL. ISMP best practices: (1) any change in drug, concentration, or bag is a high-alert checkpoint requiring an independent two-nurse double check at the bedside, including verification of the order, drug name, concentration, dose limits, basal/demand/lockout, patient identifier, and pump display; (2) use smart pumps with drug libraries and dose error reduction software (DERS) configured for the institution; (3) scan medication and patient (BCMA) when supported; (4) standardize concentrations across the institution to limit confusion; (5) post a label on the pump showing the active drug and concentration; (6) never assume opioid equivalence — hydromorphone 0.2 mg/mL is a different total dose than morphine 1 mg/mL even at identical demand volumes. Restarting without verification, mixing remnants, or delaying pharmacy contact are all unsafe. The nurse stops, verifies, reprograms, and double-checks before any restart. ## In-depth explanation Drug or concentration changes are high-alert checkpoints. Stop, verify, reprogram, and double-check — never auto-restart on the prior program. ## 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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