For a patient using a PCA pump, what is a nursing priority in monitoring?

• A. Monitor sedation level and respiratory status
• B. Replace the battery hourly
• C. Administer extra bolus doses as needed without protocol
• D. Remove the opioid without a physician order if discomfort persists

Answer: (A)

The main concept here is recognizing the risk of opioid-induced respiratory depression with a PCA pump. Opioids delivered through PCA can depress the brain’s drive to breathe, so the nursing priority is closely watching how awake the patient is and how well they are breathing. Early signs of trouble show up as increased drowsiness or decreased respiratory rate, shallow breaths, or dropping oxygen levels. By routinely assessing sedation level with a standardized scale and monitoring breathing (rate, depth, pattern, and oxygen saturation), you can detect problems early and act promptly—adjusting or stopping the PCA per protocol, providing oxygen if needed, and notifying the clinician. This focus on safety takes precedence over device checks or unsanctioned dose changes, which can introduce new risks. If overdose is suspected or confirmed, follow the facility’s protocol, including potential reversal with naloxone if ordered.