medium · NCLEX-RN basic-care
The registered nurse is assessing a 62-year-old female client who is receiving intravenous hydromorphone via a patient-controlled analgesia (PCA) pump after major abdominal surgery. The nurse finds the client somnolent, falling asleep mid-sentence during the assessment, and difficult to arouse. When stimulated, the client states, "My pain is still an 8 out of 10," and reaches for the demand button. The client's vital signs are: blood pressure 104/62 mm Hg, heart rate 64 beats/minute, respiratory rate 9 breaths/minute, and SpO2 91% on room air.
Which action should the nurse take first?
- Obtain a venous blood gas sample to evaluate the partial pressure of carbon dioxide (PCO2).
- Hold the PCA pump immediately, stimulate the client to take deep breaths, and closely monitor sedation.
- Administer a nonsteroidal anti-inflammatory drug (NSAID) as an adjunct to help lower the pain score.
- Encourage the client to press the PCA demand button to achieve adequate comfort.
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