A postoperative client who received IV morphine is difficult… | MyMerci
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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?
1Document the sedation level, continue routine monitoring, and reassess in 30 minutes.
2Stimulate the client, support breathing, and prepare to administer naloxone.✓ Correct answer
3Administer naloxone intramuscularly immediately to reverse the respiratory depression.
4Apply a nonrebreather mask with high-flow oxygen and continue to monitor oxygenation.
Explanation
This client has opioid-induced respiratory depression. Option 2 is correct: stimulate the client, support airway and ventilation, call for assistance, and prepare to administer naloxone according to protocol or prescription. Option 1 is incorrect because documenting and waiting 30 minutes permits worsening hypoxemia and respiratory arrest. Option 3 is incorrect because intramuscular naloxone has a slower onset than intravenous naloxone in an acute emergency, and immediate airway and ventilation support should not be delayed. Option 4 is incomplete because oxygen may improve saturation but does not correct severe hypoventilation or reverse the opioid effect; ventilation support and naloxone preparation are required.
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.