A respiratory rate of 8 breaths per minute with shallow breathing indicates severe opioid-induced respiratory depression, requiring immediate intervention. Other findings like pain scores or PCA usage patterns are less urgent.
심화 해설
Clinical Judgment
This question assesses the Recognize Cues and Prioritize Hypotheses stages, focusing on patient safety and risk recognition. The most life-threatening complication during PCA pump use is opioid-induced respiratory depression. Compared to a normal respiratory rate (12-20 breaths/min), a rate of 8 breaths/min with shallow breathing indicates severe respiratory depression, which can lead to hypoxia, apnea, and even respiratory arrest if treatment is delayed. This is a critical cue requiring immediate reporting and intervention. The other options represent adequacy of pain control, PCA system function, or an expected side effect of opioids (drowsiness), and are not immediate life threats.
Memory Tip:
Respiratory Rate Rules! The top priority in opioid PCA monitoring is the respiratory rate. "8 is Too Late" – a rate of 8 or less per minute is a signal for immediate intervention.
KR vs US:
While PCA use is also common in Korea, the US NGN exam particularly emphasizes the nurse's role in vigilant monitoring and independent judgment (e.g., preparing naloxone, reporting to the HCP) regarding respiratory depression. In Korean practice, it operates under a physician's order, but in the exam, the nurse's responsibility as the initial detector and first responder is the key point.
임상 시나리오
Clinical Practice Guide
Nursing points for patients using PCA (Patient-Controlled Analgesia):
1. Assess respiratory rate, depth, oxygen saturation (SpO2), and level of consciousness every 1-2 hours. A respiratory rate of less than 10 breaths/min or SpO2 below 90% is a danger sign.
2. Know the location and usage of naloxone and have it prepared.
3. Check the PCA pump records (number of attempts/number of successful deliveries) to evaluate the adequacy of pain control and system malfunction.
4. Educate the patient and caregiver to press the PCA button "when pain starts" and not "preventively."
Caution:
In SATA (Select All That Apply) questions asking about "nursing interventions related to PCA," monitoring respiratory status is always included. Do not judge opioid overdose based solely on the information that "the patient is drowsy but easily awakened." It must be assessed together with respiratory rate.
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.