A postoperative client who received IV morphine is difficult… | MyMerci
Medication AdministrationPPT
Question
A postoperative client who received IV morphine is difficult to arouse. Respirations are 7/min and oxygen saturation is 86%. Which action should the nurse take first?
1Stimulate the client, support breathing, and prepare to administer naloxone.✓ Correct answer
2Document the sedation as expected and reassess in 1 hour.
3Give the next opioid dose to prevent rebound pain.
4Place the client flat and turn off the oxygen.
Explanation
Severe sedation with respiratory depression after opioid administration is an emergency. The nurse should stimulate the client, support airway and breathing, apply oxygen as needed, and prepare for naloxone according to protocol or prescription. Delaying care or giving more opioid is unsafe.
In-depth explanation
Clinical Judgment Opioid safety is respiratory safety first.
Memory Tip Low respirations after opioid: airway, breathing, naloxone.
Clinical scenario
Clinical Practice Guide Opioid monitoring includes sedation level, respiratory rate, oxygenation, pain control, and readiness to reverse respiratory depression.
Caution Do not wait when respirations are severely depressed.
Key concepts
Morphine — An opioid analgesic that can depress respirations.
Naloxone — An opioid antagonist used to reverse serious opioid effects.
Respiratory Depression — Inadequate ventilation shown by slow or ineffective breathing.