An opioid-tolerant postoperative client receiving fentanyl b… | MyMerci
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Medication Administration PPT
Question

An opioid-tolerant postoperative client receiving fentanyl by PCA is difficult to arouse and has a respiratory rate of 7/min. Which action should the nurse take when administering prescribed intravenous naloxone?

Explanation
The immediate priorities are airway and ventilatory support plus titrated naloxone. In opioid-tolerant clients, small intravenous increments are given every 2 to 3 minutes to restore adequate ventilation without unnecessarily eliminating all analgesia or precipitating severe withdrawal. Continued monitoring is required because opioid effects can outlast naloxone.
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In-depth explanation

Clinical reasoning
Naloxone is titrated to adequate ventilation and arousal, not automatically to complete analgesic reversal. Excessive or rapid reversal can cause severe pain, withdrawal, hypertension, nausea, or circulatory stress.

Decision rule
Ventilate first, administer small IV increments at 2- to 3-minute intervals, and reassess after each dose. Continue observation for recurrent sedation or respiratory depression.
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For study reference only. Always follow current clinical guidelines and your institution’s protocols.