# A nurse is caring for a patient receiving morphine sulfate 4 mg IV every 4 hours for postoperative pain. Which assessment finding would require the nurse to withhold the medication and notify the physician immediately? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=319600 > language: ko > subject: Pharmacology ## 문제 A nurse is caring for a patient receiving morphine sulfate 4 mg IV every 4 hours for postoperative pain. Which assessment finding would require the nurse to withhold the medication and notify the physician immediately? ## 보기 1. Blood pressure 90/60 mmHg (baseline 120/80 mmHg) 2. Respiratory rate 10 breaths per minute with shallow breathing and oxygen saturation of 88% **✔ 정답** 3. Pain level reported as 8/10 on numeric rating scale 4. Drowsiness but arousable to verbal stimuli **정답: 2** ## 해설 Respiratory rate of 8 breaths/min with shallow breathing indicates severe opioid-induced respiratory depression, requiring medication withholding and physician notification. Other findings are less urgent. ## 심화 해설 Core Nursing Explanation **Key Concept Analysis**: This question tests the nurse's ability to recognize and prioritize the most serious adverse effect of opioid analgesics like morphine sulfate. The core theme is patient safety and medication administration principles. Morphine, a potent opioid, depresses the central nervous system (CNS), particularly the brainstem's respiratory centers. The most life-threatening side effect is Key Point! Respiratory depression. The nurse must assess respiratory rate, depth, and pattern before administering each dose. Withholding the medication and notifying the physician is required when the risk of harm outweighs the benefit of pain relief. **Answer Rationale**: Option ② is correct because it presents classic signs of opioid-induced respiratory depression. A respiratory rate of 10 breaths/min (normal adult range is 12-20 breaths/min) combined with shallow breathing (reduced tidal volume) and oxygen saturation of 88% (normal is >95%) indicates inadequate gas exchange and potential hypoxemia. This is an immediate safety concern that precedes the administration of another dose of a respiratory depressant. **Distractor Analysis**: - **Option ① (Blood pressure 90/60 mmHg)**: While hypotension is a known side effect of morphine (due to vasodilation and histamine release), a BP of 90/60 in a postoperative patient, while noteworthy, is not typically the *immediate* reason to withhold and call the physician unless accompanied by symptoms of shock (e.g., tachycardia, dizziness, altered mentation). The nurse would monitor closely but likely administer the medication if the patient is otherwise stable. - **Option ③ (Pain level 8/10)**: This finding indicates poor pain control and is a reason to *administer* the medication as ordered or to consider non-pharmacological interventions. It is not a reason to withhold it. - **Option ④ (Drowsiness but arousable)**: Sedation and drowsiness are common, expected side effects of opioids. Being "arousable to verbal stimuli" indicates the patient is not in a dangerous state of unresponsiveness (like stupor or coma). The nurse should monitor for progression to respiratory depression but would not typically withhold the scheduled dose based on this finding alone. **Related Concepts**: This integrates knowledge of pharmacology (opioid action), respiratory assessment, and the nursing process (specifically the *implementation* phase with a focus on safe medication administration and the *evaluation* phase for monitoring outcomes and adverse effects). Concept Summary | Concept | Key Takeaway | | --- | --- | | Opioid Adverse Effects | Respiratory depression is the most serious. Others include sedation, nausea/vomiting, constipation, urinary retention, hypotension, and pruritus. | | Nursing Assessment for Opioids | Always assess Respiratory Rate, Depth, and Pattern and Level of Consciousness (LOC) prior to administration. Use tools like the Pasero Opioid-Induced Sedation Scale (POSS). | | Nursing Action for Respiratory Depression | 1. Withhold the opioid. 2. Stimulate the patient (verbal, physical). 3. Administer oxygen. 4. Notify physician/Rapid Response Team if no improvement. 5. Be prepared to administer naloxone (Narcan), the opioid antagonist. | | Safe Medication Administration | The "Right" to refuse: A nurse has the right and responsibility to withhold a medication if assessment data indicates it would be unsafe to administer. | Side-by-Side Comparison! | Assessment Finding | Action for Scheduled Opioid | Rationale | | --- | --- | --- | | Respiratory Rate < 12, shallow, SpO2 < 90% | WITHHOLD. Notify MD immediately. | Life-threatening respiratory depression. Further opioid will worsen it. | | Sedation (sleepy but easily aroused) | Administer with caution and increased monitoring. | Expected side effect. Monitor for progression to respiratory depression. | | Uncontrolled Pain (8/10) | Administer as scheduled. Consider PRN order or non-pharm methods. | The therapeutic goal is pain relief. Inadequate treatment can impede recovery. | | Mild Hypotension (asymptomatic) | Administer, monitor BP trend. Have patient change positions slowly. | Common side effect. Not an immediate danger if patient is asymptomatic. | Anatomy, Physiology & Pharmacology Points - **Mechanism of Action**: Morphine binds to mu-opioid receptors in the CNS (brain and spinal cord), blocking pain transmission and altering perception. Its action on mu receptors in the medulla oblongata suppresses the responsiveness of brainstem respiratory centers to carbon dioxide (CO2), leading to hypoventilation. - **Antidote**: Naloxone (Narcan) is a competitive opioid antagonist. It displaces opioids from the receptors, rapidly reversing respiratory depression. Its half-life is shorter than most opioids, so re-dosing or continuous monitoring is required. Memory Tips - **Acronym: R.A.P.I.D.** for opioid overdose/toxicity: **R**espiratory depression, **A**ltered LOC (pinpoint pupils), **P**ulmonary edema (rare), **I**ntestinal slowdown (ileus), **D**eath (if untreated). - **Rule of Thumb**: "If they're not breathing well, don't give the pill (or injection)." Always check respirations FIRST. High-Frequency NCLEX Topics This is a classic High Yield NCLEX topic. Expect questions on: - Identifying the priority assessment for a patient receiving opioids. - Recognizing signs of toxicity/adverse effects (especially respiratory depression). - Knowing the appropriate nursing action (withhold, notify, administer antidote). - Understanding patient education for opioid use (take with food if nausea, prevent constipation, avoid alcohol). Watch Out for Question Variations! - **Shift from Symptom to Intervention**: "The nurse notes a postoperative patient has a respiratory rate of 9/min after receiving morphine. What is the nurse's *priority* action?" (Answer: Stimulate the patient and assess airway/breathing, then administer oxygen, then notify MD/prepare naloxone). - **Shift to Antidote Knowledge**: "A patient is unresponsive with bradypnea after an opioid overdose. Which medication should the nurse prepare to administer?" (Answer: Naloxone). - **Shift to Patient Selection**: "For which patient would the nurse question an order for morphine sulfate?" (Answer: A patient with chronic obstructive pulmonary disease (COPD) who relies on a hypoxic drive to breathe). ## 임상 시나리오 Nursing Clinical Practice Guide **Clinical Scenario**: You are the night shift nurse on a surgical unit. Mr. Johnson, 68, had a total knee replacement 18 hours ago. He has a patient-controlled analgesia (PCA) pump with morphine but also has a standing order for morphine 4mg IV q4h PRN for breakthrough pain. At 0200, he calls and rates his pain at 9/10. You prepare to administer the scheduled PRN dose. **Nursing Intervention Strategy**: - **Assessment (The "Right" Assessment)**: Before drawing up the medication, you go to the bedside. - **Primary Survey**: You immediately observe his breathing. It appears slow and shallow. You count: Respiratory Rate = 10 breaths/min. You check the pulse oximeter: SpO2 = 87% on room air. - **Neurological Assessment**: You gently shake his shoulder and call his name. He opens his eyes and mumbles but is difficult to engage (sedation scale score of 3). - **Pain Re-assessment**: Despite his sedation, he moans and points to his knee, indicating pain is still present. - **Action (Priority Nursing Intervention)**: - You **DO NOT ADMINISTER** the morphine. You place the syringe back in the medication cart. - You **stimulate the patient**: "Mr. Johnson, take a deep breath for me. Stay awake." You sit him up slightly if possible. - You apply **supplemental oxygen** via nasal cannula at 2-4 L/min and re-check SpO2. - You **notify the physician or the Rapid Response Team** immediately, reporting: "Post-op day 1 total knee patient, respiratory rate 10, shallow, SpO2 87% on room air, now 92% on 2L O2, sedated but arousable, complaining of pain. I have withheld the scheduled morphine dose." - You ensure **naloxone (Narcan)** is available at the bedside. - **Evaluation & Documentation**: - Monitor vital signs every 5-15 minutes until stable. - Document thoroughly: Pre-administration assessment findings, action taken (medication withheld), notification of provider, interventions (oxygen), patient response, and subsequent orders received. **Patient Safety and Precautions**: - Watch out for confusion! Do not confuse *expected sedation* with *impending respiratory failure*. Use a validated sedation scale. - Elderly patients and those with renal impairment are at higher risk for opioid toxicity due to decreased metabolism and excretion. - Patients with sleep apnea, COPD, or obesity are at increased risk for respiratory depression. Nursing Procedure & Medication Flow **Step-by-Step for Opioid Administration (IV)**: - **Check the order** (Drug, Dose, Route, Time, Patient). - **Perform the "Right Assessment"**: **Respiratory status** (rate, depth, SpO2) and **Level of Consciousness** are mandatory pre-checks. - **Two Patient Identifiers**. - **Administer slowly IV push** (over 4-5 minutes) to minimize side effects like hypotension. - **Stay with the patient** for several minutes after administration to monitor for acute adverse reactions. - **Re-assess pain** in 30-60 minutes to evaluate effectiveness. - **Monitor for other side effects**: Nausea (have antiemetic ready), urinary retention (assess bladder distention), constipation (initiate bowel regimen). A Word from Your Senior Nurse "Remember, as the nurse at the bedside, you are the final safety checkpoint before any medication enters a patient's body. Your assessment is more important than the order on the chart. If your patient's breathing is compromised, giving more of a drug that suppresses breathing is never the right answer, no matter how much pain they're in. Your critical thinking in that moment—assessing, recognizing the danger, withholding the dose, and escalating care—is what defines professional nursing. On the NCLEX, they are testing your ability to keep patients safe. In real life, you will save lives." ## 핵심 개념 - **Opioid-Induced Respiratory Depression** — A life-threatening slowing of breathing caused by opioid drugs depressing the brain's respiratory centers. Characterized by bradypnea ( - **Naloxone** — An opioid receptor antagonist used as an antidote to reverse the effects of opioid overdose, especially respiratory depression. It competes with opioids for receptor sites. - **Sedation Scale (e.g., Pasero Opioid-Induced Sedation Scale - POSS)** — A tool used to systematically assess a patient's level of sedation when receiving opioids, helping to identify progression from normal sleepiness to dangerous respiratory depression. - **Patient-Controlled Analgesia** — A method of pain control where the patient self-administers preset doses of analgesic (usually opioid) via an IV pump by pressing a button, allowing for more consistent pain relief. - **Mu-Opioid Receptors** — The primary receptors in the central and peripheral nervous system to which morphine and similar drugs bind to produce analgesia, euphoria, and the unwanted side effects of respiratory depression and sedation. ## 같은 주제 문제 - [A nurse is caring for a patient receiving morphine sulfate via patient-controlled analgesi…](https://mymerci.kr/pages/nclex_q.php?qn_id=319599) - [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._