A nurse is caring for a patient receiving hydromorphone via continuous intravenous infusion for severe trauma pain. Which assessment finding requires the nurse's immediate intervention?

1 Patient reports pain level of 6/10 on the numeric rating scale
2 Respiratory rate of 8 breaths per minute with shallow breathing ✓ 정답
3 Patient experiences nausea and requests antiemetic medication
4 Blood pressure reading of 110/70 mmHg, decreased from baseline of 130/80 mmHg

해설

Respiratory rate of 8 breaths per minute with shallow breathing indicates severe respiratory depression from opioids, requiring immediate intervention like stopping morphine and administering naloxone. Other findings are less urgent.

같은 주제 다음 문제A nurse is assessing a patient who has been receiving morphine sulfate 10 mg IV every 4 ho…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX),이거 하나면 됩니다89,000원 · 무료 체험 가능

심화 해설

Clinical Judgment This question assesses patient safety prioritization and risk recognition. Continuous intravenous morphine infusion provides effective pain relief, but its most dangerous side effect, respiratory depression, must be continuously monitored. In option 2, "respiratory rate 8 breaths/min and shallow breathing" is a life-threatening Critical Cue. This indicates severe central respiratory depression due to morphine dose accumulation or a hypersensitivity reaction, requiring immediate intervention (stopping the infusion, notifying the physician, preparing to administer naloxone). The other options are important but are not immediate life threats. Pain 6/10 requires analgesic adjustment but is not an emergency, nausea is a common side effect, and blood pressure 110/70 is near normal range, and a decrease from baseline does not indicate severe hypotension. Memory Tip: Respiratory Rate First! The first principle of opioid monitoring is always the respiratory rate. Remember the order of "Airway, Breathing, Circulation." If breathing stops, everything else is meaningless. KR vs US: In Korea, opioid use may be relatively conservative, but in the NGN/US exams, aggressive cancer pain management and subsequent side effect monitoring are emphasized. The response protocol for respiratory depression (such as naloxone use) is highly systematic, and there are many questions evaluating the nurse's independent judgment and immediate intervention skills.

임상 시나리오

Clinical Practice Guide When managing a patient receiving continuous intravenous opioids (including Patient-Controlled Analgesia): 1. Regularly assess respiratory rate, depth, pattern, and oxygen saturation (SpO2) (every 1-2 hours per hospital policy). 2. Intervene immediately if the respiratory rate falls below 12 breaths per minute, depth becomes markedly shallow, or SpO2 drops below 90%. 3. Changes in level of consciousness (drowsiness, confusion) can also be early signs of respiratory depression. 4. Know the location and usage of naloxone. Caution: In SATA (Select All That Apply) questions asking about "morphine side effects," respiratory depression must be included along with nausea/vomiting, constipation, itching, urinary retention, sedation, etc. If asked to choose the "most serious" or "must be reported immediately," respiratory depression is the only correct answer. Hypotension is a side effect of opioids, but has a lower priority than respiratory depression.

핵심 개념

Respiratory Depression — Respiratory depression. A condition where the respiratory rate decreases and breathing becomes shallow, and it is the most serious side effect of opioid medications. It can be life-threatening.
Opioid — Opioids. A class of drugs, including morphine, fentanyl, and oxycodone, that act on opioid receptors in the central nervous system to produce analgesic effects. They are effective for pain control but carry risks of side effects such as respiratory depression.
Naloxone — Naloxone. An opioid antagonist, it is an emergency medication used for opioid overdose or severe respiratory depression. It reverses the effects by blocking opioid receptors.
Bradycardia — Bradycardia. It generally refers to a slow heart rate of less than 60 beats per minute. In this context, it is closely related to 'Bradypnea' (slow breathing). Respiratory depression often presents as Bradypnea.
Continuous Intravenous Infusion — Continuous intravenous infusion. This is a method of administering medication continuously through a vein at a constant rate. It can maintain stable blood levels, but monitoring for side effects is especially important due to the risk of drug accumulation.

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A nurse is caring for a patient receiving hydromorphone via continuous intravenous infusion for severe trauma pain. Which assessment finding requires the nurse's immediate intervention?

심화 해설

임상 시나리오

핵심 개념

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