# A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA) pump for postoperative pain management. Which assessment finding would require the nurse to take immediate action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=319599 > language: ko > subject: Pharmacology ## 문제 A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA) pump for postoperative pain management. Which assessment finding would require the nurse to take immediate action? ## 보기 1. Patient reports pain level of 6/10 on numeric rating scale 2. Patient appears drowsy but arouses easily to verbal stimuli 3. Patient's blood pressure is 110/70 mmHg (baseline 120/80 mmHg) 4. Patient's respiratory rate is 8 breaths per minute with shallow breathing **✔ 정답** **정답: 4** ## 해설 Respiratory rate of 8 breaths/min with shallow breathing indicates severe opioid-induced respiratory depression, requiring immediate intervention like stopping PCA and notifying the provider. Other findings (pain 6/10, drowsiness arousable to stimuli, slight BP drop) are expected or less critical. ## 심화 해설 Core Nursing Explanation **Key Concept Analysis**: This question tests the critical assessment of a patient on opioid-based Patient-Controlled Analgesia (PCA). The core theme is recognizing life-threatening adverse effects versus expected or less severe side effects. Opioids like morphine sulfate act on central nervous system (CNS) receptors, providing analgesia but also suppressing the brainstem's respiratory centers. The priority nursing action is always to protect the patient's Key Point! **Airway, Breathing, and Circulation (ABC)**. Respiratory depression is the most dangerous complication of opioid therapy. **Answer Rationale**: A respiratory rate of 8 breaths per minute with shallow breathing is a clear sign of respiratory depression. Normal adult respiratory rate is 12-20 breaths per minute. A rate this low, especially with poor depth (shallow), indicates inadequate gas exchange, leading to hypoxemia (low blood oxygen) and hypercapnia (high blood carbon dioxide). This requires immediate action: stopping the PCA pump, administering the opioid reversal agent naloxone as prescribed, stimulating the patient, providing oxygen, and notifying the provider. **Distractor Analysis**: Watch out for confusion! Option ①: A pain level of 6/10 indicates inadequate pain control and requires reassessment and possible PCA dose adjustment, but it is not an immediate life-threatening finding. Option ②: Drowsiness that is easily reversed (arousable to verbal stimuli) is a common and expected side effect of opioids, known as sedation. The nurse should continue to monitor the level of sedation using a tool like the Pasero Opioid-Induced Sedation Scale (POSS), but it does not require the same urgent intervention as respiratory depression. Option ③: A blood pressure of 110/70 mmHg from a baseline of 120/80 mmHg is a mild decrease. Opioids can cause vasodilation and orthostatic hypotension, but this reading is not critically low and would be monitored, not acted upon immediately. **Related Concepts**: Understanding the nursing management of PCA pumps is essential. This includes patient education on self-administration, monitoring for the "5 P's" of opioid overdose: **P**inpoint pupils, **P**ulmonary depression (slow breathing), **P**eripheral cyanosis, **P**oor perfusion (hypotension, bradycardia), and **P**ostural hypotension. Nurses must also understand the use and mechanism of naloxone, a competitive opioid antagonist. Concept Summary | Concept | Description | Nursing Implication | | --- | --- | --- | | PCA (Patient-Controlled Analgesia) | A system allowing patients to self-administer preset doses of analgesic medication (e.g., morphine) via an IV pump. | Educate patient on proper use (push button for pain, not for anxiety). Only the patient should press the button. Monitor for efficacy and safety. | | Opioid-Induced Respiratory Depression | The most serious adverse effect of opioids, characterized by a decreased respiratory rate ( | Immediate action required! Stop infusion, administer naloxone, stimulate patient, provide O2, call rapid response if needed. | | Sedation vs. Respiratory Depression | Sedation (drowsiness) often precedes respiratory depression. Use a sedation scale (e.g., POSS) to monitor progression. | A patient who is difficult to arouse (POSS level 3 or 4) is at high risk for respiratory depression and requires intervention. | | Naloxone (Narcan) | Opioid antagonist. Competitively binds to opioid receptors, reversing effects like respiratory depression. | Administer per protocol for respiratory depression. Effects are short-lived (20-90 min), so continuous monitoring is needed as the opioid may outlast the naloxone. | Side-by-Side Comparison! | Assessment Finding | Significance | Required Nursing Action | | --- | --- | --- | | Respiratory Rate 8/min, shallow | Critical. Indicates respiratory depression, risk of arrest. | Immediate. Stop PCA, give naloxone, stimulate, O2, notify provider/rapid response. | | Pain score 6/10 | Abnormal. Indicates poor pain control. | Timely. Reassess pain, check PCA settings/history, consider non-pharmacologic measures, notify provider for possible dose adjustment. | | Drowsy but easily aroused | Expected/Caution. Common opioid side effect (sedation). | Monitor. Continue frequent assessments using a sedation scale. Re-educate patient/family on safety (call light, fall prevention). | | BP 110/70 (baseline 120/80) | Within Normal Limits/Caution. Mild orthostatic hypotension possible. | Monitor. Encourage slow position changes. Assess for dizziness. Not an immediate threat. | Anatomy, Physiology & Pharmacology Points - **Physiology/Patho**: Opioids (morphine) bind to mu-opioid receptors in the brainstem, particularly the medulla oblongata. This depresses the respiratory center, reducing the sensitivity to carbon dioxide (CO2), leading to **hypoventilation**. - **Pharmacology**: Naloxone has a higher affinity for opioid receptors than morphine but a shorter duration of action. This is why repeated doses or a continuous infusion may be needed after initial reversal. - **Assessment**: Always assess **rate, rhythm, and depth** of respirations. Shallow breathing (reduced tidal volume) is as dangerous as a slow rate. Memory Tips - **ABCs First**: Always assess Airway, Breathing, Circulation before anything else. A problem with "B" (Breathing) is always a top priority. - **The Rule of 12**: A respiratory rate < 12 breaths/min in an adult on opioids is a red flag for respiratory depression. - **Sedation Scale**: Remember "S" comes before "R" – **S**edation often precedes **R**espiratory depression. Monitor sedation levels closely! High-Frequency NCLEX Topics This is a **High Yield** topic. The NCLEX-RN loves to test: - Priority setting (Which finding requires immediate action?). - Medication side effects and nursing interventions, especially for high-alert drugs like opioids. - Interpretation of assessment data (vital signs, pain scores, level of consciousness). - Proper use and monitoring of medical devices (PCA pumps). Watch Out for Question Variations! - **Shift from Symptom to Intervention**: "The nurse notes a patient on a morphine PCA has a respiratory rate of 9/min. Which action should the nurse take *first*?" (Answer: Stop the PCA infusion). - **Shift to Medication Administration**: "A patient experiencing opioid-induced respiratory depression is prescribed naloxone. The nurse understands this drug acts by which mechanism?" (Answer: Competitive antagonism at opioid receptor sites). - **Shift to Patient Education**: "When teaching a patient about PCA use, which statement by the patient indicates a need for further teaching?" (Answer: "My family member can press the button for me if I'm sleeping."). ## 임상 시나리오 Nursing Clinical Practice Guide **Clinical Scenario**: You are the night shift nurse on a surgical floor. Mr. Johnson, 68, is 12 hours post-op from a total knee replacement. He has a morphine PCA ordered: 1 mg demand dose with a 10-minute lockout interval. During your 2 AM rounds, you find him sleeping soundly. You gently call his name; he mumbles but does not fully wake up. You count his respirations for a full minute: rate is 9, and his chest movement is very shallow. **Nursing Intervention Strategy**: - **Immediate Action (Within seconds)**: Key Point! Gently but firmly shake the patient's shoulder and say his name loudly. **If he does not rouse easily, this is a medical emergency.** Immediately press the nurse call button for help. - **Assess and Intervene for ABCs**: - **Airway**: Ensure it is patent. Perform a head-tilt/chin-lift if needed (if no spinal precautions). - **Breathing**: Stop the PCA pump. Administer supplemental oxygen via nasal cannula or non-rebreather mask as per protocol or standing order. - **Circulation**: Check pulse and blood pressure. - **Administer Reversal Agent**: Based on your hospital's protocol or a stat order, prepare and administer naloxone (e.g., 0.4 mg IV push). Be prepared to repeat doses every 2-3 minutes as the patient's respiratory status is reassessed. - **Notify and Document**: Activate the Rapid Response Team (RRT) or call the provider immediately. Document everything meticulously: time of assessment, vital signs, your actions (PCA stopped, O2 applied, naloxone given), patient response, and notifications made. **Patient Safety and Precautions**: - **Never leave the patient alone** once respiratory depression is suspected. - **Know your equipment**: Be proficient in operating and pausing the specific PCA pump model on your unit. - **Naloxone Precautions**: Be aware that naloxone will also reverse the analgesic effects, causing severe pain to return suddenly. The patient may become agitated or combative. Have assistance and safety measures ready. - **Continuous Monitoring**: After the event, the patient will require very frequent monitoring (every 15-30 minutes) for several hours as the effects of naloxone wear off and the opioid may still be in their system. Nursing Procedure & Medication Flow **Procedure: Responding to Opioid-Induced Respiratory Depression** 1. **Assess**: Stimulate patient. Count respirations for 60 seconds, noting depth. 2. **Activate**: Call for help (another nurse, RRT). 3. **Airway/Breathing**: Position patient, administer 100% oxygen. 4. **Stop the Source**: Pause/stop the PCA infusion. 5. **Administer Antidote**: Draw up naloxone per order/protocol. Administer IV push slowly. 6. **Reassess**: Monitor respirations, pulse oximetry, level of consciousness every 2-3 minutes. 7. **Support**: Stay with patient, explain actions, manage pain re-emergence. 8. **Document & Debrief**: Complete event report and notify provider. **Medication: Naloxone (Narcan)** - **Class**: Opioid antagonist. - **Action**: Competitively binds to opioid receptor sites, reversing CNS and respiratory depression. - **Dose/Route**: Typical initial dose 0.4 mg to 2 mg IV, IM, or SQ. IV route has fastest onset (1-2 minutes). - **Nursing Considerations**: Onset is rapid, duration is short (20-90 minutes). **Continuous monitoring is mandatory** as re-sedation can occur. Have multiple doses available. A Word from Your Senior Nurse "Managing a patient on a PCA pump is a classic example of nursing vigilance. It's a fantastic tool for patient autonomy and pain control, but it puts a huge responsibility on us. We are the safety net. Never become complacent with 'set it and forget it.' Your regular, purposeful rounding—actually watching the chest rise and fall, not just glancing at the monitor—is what saves lives. On the NCLEX, they are testing your ability to recognize the one finding that can't wait. In real life, that skill, coupled with the confidence to act swiftly, is what makes an exceptional nurse. Remember your ABCs, know your antidotes, and trust your assessment." ## 핵심 개념 - **Patient-Controlled Analgesia** — A drug delivery system that allows patients to self-administer preset doses of analgesic medication (usually opioids) via an intravenous pump by pressing a button, within programmed safety limits. - **Opioid-Induced Respiratory Depression** — A potentially life-threatening adverse effect of opioids characterized by a decreased respiratory rate ( - **Naloxone** — An opioid antagonist medication used to rapidly reverse the effects of opioid overdose, including respiratory depression, by competitively binding to opioid receptor sites. It has a short duration of action. - **Sedation Scale (e.g., POSS)** — A tool used to systematically assess and document a patient's level of sedation, often used for patients on opioid therapy to monitor for progression from expected drowsiness to dangerous oversedation that precedes respiratory depression. - **Hypoventilation** — Inadequate ventilation leading to an increase in arterial carbon dioxide (PaCO2) and a decrease in oxygen (PaO2). In the context of opioids, it is caused by reduced respiratory drive and shallow breathing. ## 같은 주제 문제 - [A nurse is caring for a patient receiving morphine sulfate 4 mg IV every 4 hours for posto…](https://mymerci.kr/pages/nclex_q.php?qn_id=319600) - [A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesi…](https://mymerci.kr/pages/nclex_q.php?qn_id=319601) - [A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesi…](https://mymerci.kr/pages/nclex_q.php?qn_id=319602) - [A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesi…](https://mymerci.kr/pages/nclex_q.php?qn_id=319603) - [A nurse is assessing a patient who has been receiving morphine sulfate 10 mg IV every 4 ho…](https://mymerci.kr/pages/nclex_q.php?qn_id=319604) - [A nurse is assessing a patient who has been receiving morphine sulfate 10 mg IV every 4 ho…](https://mymerci.kr/pages/nclex_q.php?qn_id=319605) - [A nurse is caring for a patient receiving continuous morphine infusion for severe cancer p…](https://mymerci.kr/pages/nclex_q.php?qn_id=319634) - [A nurse is caring for a patient receiving hydromorphone via continuous intravenous infusio…](https://mymerci.kr/pages/nclex_q.php?qn_id=319635) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._