Opioid Analgesics

A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA) pump. Which assessment finding requires the nurse's immediate intervention?

1 Patient reports pain level of 6/10 on the numeric rating scale
2 Patient's blood pressure is 110/70 mmHg (baseline 120/80 mmHg)
3 Patient appears drowsy but arouses easily to verbal stimuli
4 Patient's respiratory rate is 8 breaths per minute with shallow breathing ✓ 정답

해설

Respiratory rate of 8 breaths/min with shallow breathing indicates severe opioid-induced respiratory depression requiring immediate intervention. Other findings (pain, mild hypotension, drowsiness) are expected or 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 됩니다69,000원

Understanding the Priority: Airway and Breathing
When using a PCA pump, the most critical adverse effect to monitor for is opioid-induced respiratory depression (OIRD). The provided case report highlights that OIRD can have an insidious onset and progress rapidly to cardiorespiratory collapse, even in patients without traditional risk factors ^[1]. In the NCLEX-RN prioritization framework, an assessment finding indicating a compromised airway or breathing pattern always takes precedence over pain or mild changes in consciousness.

Analysis of Assessment Findings
The nurse must differentiate between expected therapeutic effects, manageable side effects, and life-threatening complications of morphine sulfate.

- Option 1: A pain level of 6/10 indicates inadequate analgesia. While this requires intervention, such as evaluating the PCA settings or considering adjuvant therapy, unrelieved pain is not immediately life-threatening. The patient’s airway and breathing are currently stable.
- Option 2: A blood pressure of 110/70 mmHg from a baseline of 120/80 mmHg represents a mild decrease. Morphine causes vasodilation and can lower blood pressure, but this reading remains within a normotensive range and does not signal hemodynamic instability.
- Option 3: Drowsiness where the patient arouses easily to verbal stimuli is a common and expected effect of opioid therapy, reflecting sedation without a compromised airway. The key safety distinction here is that the patient is easily arousable, meaning protective airway reflexes are likely intact.
- Option 4: A respiratory rate of 8 breaths per minute with shallow breathing is the classic clinical presentation of OIRD. Opioids bind to mu-receptors in the brainstem’s respiratory centers, blunting the responsiveness to rising carbon dioxide levels. This finding indicates that the patient’s ventilation is critically compromised, which can lead to hypercapnia, hypoxemia, and eventual respiratory arrest ^[1].

Clinical Reasoning and Immediate Action
The nurse must recognize that a respiratory rate below 10 breaths per minute in an adult receiving opioids signifies severe respiratory depression. The shallow depth further reduces alveolar ventilation. This scenario directly aligns with the pathophysiology described in the case report, where the subtle progression of OIRD can quickly become fatal if not promptly identified and reversed ^[1]. The immediate nursing intervention is to stop the PCA pump, administer supplemental oxygen, vigorously stimulate the patient to breathe, and prepare to administer an opioid antagonist like naloxone as prescribed.

References (research sources)

[1]
Insidious opioid-induced respiratory depression following abdominal steel pipe perforation injury: A case report.Case reportZhang X, Qiao S, Pan H. (2025) · DOI: 10.1097/md.0000000000045435

NCLEX Question Bank 엔클렉스 3,445 문제 · 로그인 없이 바로 볼 수 있어요

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기

App Store Google Play

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.

이 문제가 수록된 문제집 [개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다 문제집 3,445문제 · 69,000원

문제집 보기 다음 문제

같은 단원 문제

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기

다음 문제 무료로 시작하기

성장을 멈추지 마세요

A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA) pump. Which assessment finding requires the nurse's immediate intervention?

마이메르시로 국가고시 완벽 대비