# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=319601 > language: ko > subject: Pharmacology ## 문제 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? ## 보기 1. Patient reports pain level of 6/10 on numeric rating scale 2. Patient's blood pressure is 110/70 mmHg (baseline 120/80 mmHg) 3. Patient's respiratory rate is 8 breaths per minute with shallow breathing **✔ 정답** 4. Patient appears drowsy but arouses easily to verbal stimuli **정답: 3** ## 해설 Respiratory rate of 8 breaths/min with shallow breathing indicates opioid-induced respiratory depression requiring immediate intervention. Other findings (pain 6/10, mild BP drop, drowsiness) are expected or less critical. ## 심화 해설 Core Nursing Explanation **Key Concept Analysis**: This question assesses the nurse's ability to recognize and prioritize life-threatening adverse effects of opioid analgesics, specifically when administered via a Patient-Controlled Analgesia (PCA) pump. The core theme is opioid-induced respiratory depression, which is the most serious and potentially fatal side effect of drugs like morphine sulfate. The nurse must understand that while managing pain is important, maintaining a patent airway and adequate ventilation is the top priority (following the ABCs: Airway, Breathing, Circulation). **Answer Rationale**: Key Point! A respiratory rate of 8 breaths per minute with shallow breathing is a critical sign of respiratory depression. The normal adult respiratory rate is 12-20 breaths per minute. A rate below 10, especially when accompanied by shallow depth (reduced tidal volume), indicates significant central nervous system depression and hypoventilation. This can rapidly lead to hypoxia, hypercapnia (elevated CO2), respiratory acidosis, and respiratory arrest. This finding requires immediate intervention, which includes stopping the PCA pump, stimulating the patient, administering the opioid antagonist Naloxone (Narcan) as prescribed, and providing respiratory support. **Distractor Analysis**: Watch out for confusion! Option ①: A pain level of 6/10 indicates the PCA may need adjustment for better pain control, but it is not an immediate, life-threatening concern. The patient's report of pain should be addressed, but it does not supersede the ABCs. Option ②: A blood pressure of 110/70 mmHg from a baseline of 120/80 mmHg represents a mild, expected hypotensive effect of opioids due to vasodilation and histamine release. While the nurse should monitor for further drops, this finding alone does not require immediate action. Option ④: Drowsiness that resolves with verbal stimuli (arousable) is a common and expected side effect of opioids, known as sedation. The nurse should continue to monitor the patient's level of consciousness using a tool like the Pasero Opioid-Induced Sedation Scale (POSS), but this level of sedation is not an emergency. The critical threshold is when a patient becomes unarousable. **Related Concepts**: Safe PCA use requires vigilant monitoring of the "5 P's": Pain relief, Pulse oximetry (SpO2), Pressure (blood pressure), Pupils (for pinpoint pupils - miosis), and **Particularly** Patency of airway and Respiratory rate/pattern. Understanding the mechanism of action of opioids (binding to mu receptors in the brain and spinal cord, which alters pain perception but also depresses the brainstem's respiratory centers) is crucial for anticipating this side effect. Concept Summary | Concept | Key Points | | --- | --- | | PCA (Patient-Controlled Analgesia) | IV delivery system allowing patient to self-administer preset doses of analgesic (e.g., morphine). Requires nurse monitoring for safety. | | Opioid-Induced Respiratory Depression | Most serious adverse effect. Caused by depression of brainstem respiratory centers. Signs: RR < 10/min, shallow breathing, SpO2 < 90%, somnolence. | | Naloxone (Narcan) | Opioid antagonist. Reverses respiratory depression. Administered IV for rapid effect. Duration is shorter than most opioids, requiring re-dosing. | | Nursing Priorities (ABCs) | Airway, Breathing, Circulation. Respiratory status is always the priority assessment for patients on opioid therapy. | Side-by-Side Comparison! | Assessment Finding | Clinical Significance with Opioids | Required Nursing Action | | --- | --- | --- | | Respiratory Rate 8/min, shallow | Critical. Indicates respiratory depression. | IMMEDIATE INTERVENTION: Stop PCA, stimulate, administer naloxone, call for help, prepare for bag-valve-mask ventilation. | | Sedation (drowsy but arousable) | Common side effect. Monitor using sedation scale (e.g., POSS). | Continue frequent monitoring. Consider dose adjustment. Not an emergency if patient is easily aroused. | | Pain level 6/10 | Indicates inadequate pain control. | Assess PCA settings/use, non-pharmacologic measures, collaborate with provider for possible dose adjustment. | | Mild hypotension (BP 110/70) | Expected side effect due to vasodilation. | Monitor for dizziness/falls. Encourage slow position changes. Not typically an emergency. | Anatomy, Physiology & Pharmacology Points - **Physiology/Patho**: Opioids (morphine) act on mu-opioid receptors in the medulla oblongata, depressing the responsiveness of the brainstem respiratory centers to carbon dioxide (CO2). This leads to decreased respiratory rate and tidal volume. - **Pharmacology**: Naloxone is a competitive opioid antagonist. It has a higher affinity for opioid receptors than morphine but a shorter half-life (20-60 mins). This is why re-dosing may be necessary. - **Assessment**: Always assess **both rate AND depth** of respirations. Shallow breathing (reduced depth) is as dangerous as a slow rate. Memory Tips - **Mnemonic for Opioid Overdose/Depression**: "**B**radypnea, **U**narousable, **P**inpoint pupils, **S**hallow breathing" = **BUPS** (Think: This patient has the "BUPS" and needs Narcan!). - **Rule of Thumb**: For adults on opioids, a respiratory rate < 10 breaths/min is a **RED FLAG**. - Connect the dots: Morphine → Brainstem Depression → Slow/Shallow Breathing → Low Oxygen/High CO2 → Respiratory Arrest. High-Frequency NCLEX Topics NCLEX loves to test **priority-setting** and **adverse drug reactions**. Opioid respiratory depression is a classic example. You will see questions asking: - "Which finding requires *immediate* intervention?" (Like this one). - "The nurse should monitor for which *most serious* side effect?" - "Which patient should the nurse assess *first*?" (The one with RR of 8 vs. others with pain or nausea). Always apply the ABC framework to determine the answer. Watch Out for Question Variations! - **Shift from Symptom to Action**: Instead of identifying the symptom, the question may ask: "The nurse notes a patient on a morphine PCA has a respiratory rate of 8/min. What is the nurse's *priority action*?" (Answer: Administer naloxone as prescribed/available and stimulate the patient). - **Shift to Patient Education**: "When teaching a patient about PCA use, which statement by the patient indicates a need for further teaching?" (Answer: "I should push the button whenever I feel a little sleepy to help me rest." – Wrong! PCA is for pain, not sedation). - **Adding Comorbidities**: The patient may have COPD or sleep apnea, which increases their risk for respiratory depression. The correct answer will still be the one addressing the compromised airway/breathing. ## 임상 시나리오 Nursing Clinical Practice Guide **Clinical Scenario**: You are the night shift nurse caring for Mr. Johnson, a 65-year-old post-op day 1 from a total knee replacement. He is on a morphine PCA pump. During your 2 AM rounds, you find him sleeping. You gently call his name, and he only groans without opening his eyes. You immediately assess his vital signs. **Nursing Intervention Strategy**: - **Immediate Assessment (ABCs)**: Check responsiveness. If unarousable with verbal stimuli, attempt a tactile stimulus (shake shoulder). Simultaneously, look at his chest rise (depth) and count respirations for a full 30 seconds. You find his RR is 8 and shallow. Check pulse oximetry (SpO2 reads 88%). - **Immediate Actions**: - **Stop the PCA pump** to prevent further opioid delivery. - **Call for help** (use call light or shout for another nurse). - **Position**: Sit the patient upright if possible to maximize lung expansion. - **Stimulate**: Say "Mr. Johnson, take a deep breath!" Rub his sternum (sternal rub) to attempt arousal. - **Administer Naloxone**: Per protocol or provider's standing order, prepare and administer Naloxone 0.4 mg IV push. - **Prepare for Advanced Support**: Have bag-valve-mask (BVM) and suction ready at bedside. - **Post-Intervention Monitoring**: After naloxone administration, reassess respirations, SpO2, and level of consciousness every 5-15 minutes. **Remember**: Naloxone's effects wear off before the opioid, so the patient can slip back into respiratory depression. Continuous monitoring is essential. Notify the provider immediately. **Patient Safety and Precautions**: - **Contraindications/Cautions**: Use extreme caution with opioids in patients with asthma, COPD, sleep apnea, renal/liver impairment, or concurrent use of other CNS depressants (benzodiazepines, alcohol). - **Monitoring**: For the first 24 hours on a PCA, monitor respiratory rate, depth, SpO2, and sedation level **at least every 1-2 hours**. Use a validated sedation scale. - **PCA Pump Safety**: Ensure only the patient pushes the button. Family members or nurses should **never** push the PCA button for the patient, as this bypasses the safety feature of patient arousal. Nursing Procedure & Medication Flow **Naloxone Administration (for Opioid Overdose/Respiratory Depression)**: - **Assessment**: Confirm signs of opioid toxicity (RR < 10, pinpoint pupils, unresponsiveness). - **Preparation**: Draw up Naloxone 0.4 mg (1 mL of standard concentration) into a syringe. - **Administration**: Administer IV push slowly over 30 seconds. If no IV access, give IM or via nebulizer per protocol. - **Evaluation**: Expect improvement in respiratory rate and consciousness within 1-2 minutes. If no response, may repeat dose every 2-3 minutes as ordered. - **Documentation**: Document pre-intervention status, time/dose/route of naloxone given, patient's response, and notification of provider. A Word from Your Senior Nurse Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, recognizing subtle changes in a patient's vital signs early can prevent deterioration. With PCA pumps, never let your guard down. That "peacefully sleeping" patient might be slipping into respiratory depression. Your vigilant, frequent assessments are their lifeline. When studying for your boards, don't just memorize "respiratory rate < 10" — connect it to the real feeling of anxiety when you can't wake a patient, the swift action of drawing up Narcan, and the relief when they take a deep breath and open their eyes. That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse! ## 핵심 개념 - **Patient-Controlled Analgesia** — A medication delivery system that allows patients to self-administer preset doses of analgesic medication (usually opioids) intravenously by pressing a button. It provides more consistent pain control and a sense of autonomy. - **Opioid-Induced Respiratory Depression** — A life-threatening adverse effect of opioids characterized by decreased respiratory rate ( - **Naloxone** — An opioid antagonist medication used to rapidly reverse the effects of opioid overdose, including respiratory depression, sedation, and hypotension. It competitively binds to opioid receptors, displacing the opioid agonist. - **Pasero Opioid-Induced Sedation Scale** — A validated tool used to assess the level of sedation in patients receiving opioid therapy. It helps nurses objectively monitor for progressive sedation, a precursor to respiratory depression. - **Mu-opioid Receptors** — The primary receptors in the central nervous system (brain and spinal cord) to which opioid medications like morphine bind. Activation produces analgesia (pain relief), euphoria, sedation, and respiratory depression. ## 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 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=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._