# A nurse is caring for a patient receiving hydromorphone via continuous intravenous infusion for severe trauma pain. Which assessment finding requires the nurse's immediate intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319635  
> language: ko  
> subject: Pharmacology

## 문제

A nurse is caring for a patient receiving hydromorphone via continuous intravenous infusion for severe trauma pain. Which assessment finding requires the nurse's immediate intervention?

## 보기

1. Patient reports pain level of 6/10 on the numeric rating scale
2. Respiratory rate of 8 breaths per minute with shallow breathing **✔ 정답**
3. Patient experiences nausea and requests antiemetic medication
4. Blood pressure reading of 110/70 mmHg, decreased from baseline of 130/80 mmHg

**정답: 2**

## 해설

Respiratory rate of 8 breaths per minute with shallow breathing indicates severe respiratory depression from opioids, requiring immediate intervention like stopping morphine and administering naloxone. Other findings are less urgent.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question tests the nurse's ability to recognize and prioritize a life-threatening adverse effect of opioid analgesics. The core theme is Patient Safety and Opioid-Induced Respiratory Depression (OIRD). Hydromorphone is a potent opioid agonist that binds to mu-opioid receptors in the brainstem, depressing the respiratory center. A respiratory rate of 8 breaths/min with shallow breathing is a critical sign of severe respiratory depression, which can rapidly progress to apnea, hypoxia, and death if not addressed immediately.

**Answer Rationale**: Key Point! The ABCs (Airway, Breathing, Circulation) of patient assessment dictate that compromised breathing is always a top priority. A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths/min) and indicates the infusion must be stopped, the provider notified, and the opioid antagonist Naloxone (Narcan) prepared for administration per protocol. This finding requires immediate intervention to prevent respiratory arrest.

**Distractor Analysis**:

① Watch out for confusion! A pain level of 6/10 indicates inadequate pain control and requires reassessment and possible titration of the analgesic, but it is not an immediate life-threatening concern. The nurse should address this, but not before securing the patient's airway and breathing.

③ Nausea is a common, non-life-threatening side effect of opioids. Administering a prescribed antiemetic is an appropriate nursing action, but it does not supersede the priority of managing respiratory depression.

④ A blood pressure of 110/70 mmHg, while a decrease from baseline, is still within a normal range and likely reflects the expected vasodilatory effect of opioids. The nurse should continue to monitor for hypotension, but this finding alone does not indicate an immediate crisis compared to a respiratory rate of 8.

**Related Concepts**: This integrates knowledge of Pharmacology (opioid mechanism and reversal), Nursing Assessment (vital sign interpretation and prioritization), and Emergency Response. Understanding the concept of Sedation Scales (like the Pasero Opioid-Induced Sedation Scale) is also crucial for early detection of OIRD before respiratory rate drops critically.

Concept Summary

**Opioid Safety & Monitoring:** Respiratory Rate & Depth > Sedation Level > Pain Score > Other Side Effects (N/V, Constipation, Urinary Retention, Pruritus).

**Immediate Actions for OIRD:** Stop opioid, Stimulate patient, Administer oxygen, Call for help, Prepare/Administer Naloxone.

**Normal Adult Vital Signs:** RR: 12-20, SpO2: >95%, BP: ~120/80.

Side-by-Side Comparison!

| Assessment Finding | Clinical Significance | Priority & Action |
| --- | --- | --- |
| RR 8, shallow | Severe Respiratory Depression (OIRD) | HIGHEST. Stop opioid, stimulate, give O2, prepare Naloxone. |
| Sedation Score 3 (sleepy, drifts off) | Moderate Sedation (Precursor to OIRD) | HIGH. Hold next dose, increase monitoring frequency, notify provider. |
| Pain 6/10 | Inadequate Analgesia | MODERATE. Reassess, consider non-pharm interventions, discuss titration with provider. |
| Nausea/Vomiting | Common Opioid Side Effect | ROUTINE. Administer prescribed antiemetic, provide comfort measures. |

Anatomy, Physiology & Pharmacology Points

**Pathophysiology:** Opioids act on mu-receptors in the medulla oblongata, decreasing its sensitivity to CO2. This blunts the hypercapnic drive to breathe.

**Drug Mechanism:** Naloxone is a competitive opioid antagonist. It has a shorter half-life than most opioids (e.g., hydromorphone), so re-sedation and respiratory depression can occur after its effects wear off, requiring continued close monitoring.

Memory Tips

**Mnemonic for Opioid Side Effects to Monitor:** "**R**espiration, **S**edation, **P**ain, **N**ausea" (in priority order!).

**Rule of Thumb:** A respiratory rate < 10 breaths/min in an adult on opioids is a **RED FLAG**.

High-Frequency NCLEX Topics
NCLEX heavily tests prioritization (ABCs) and recognition of adverse drug reactions. Opioid safety is a classic "select all that apply" or "priority action" question. Know the signs of OIRD and the steps for naloxone administration.

Watch Out for Question Variations!
* Instead of "which finding requires immediate action?", it could be: "The nurse notes the patient's respiratory rate is 8/min. Which action should the nurse take **first**?" (Answer: Stimulate the patient and assess airway patency).
* The scenario could involve Patient-Controlled Analgesia (PCA) instead of a continuous IV infusion. The principles of monitoring are identical.
* A question might ask for the **anticipated** effect of naloxone administration (e.g., reversal of sedation and respiratory depression, but also sudden onset of pain and potential withdrawal symptoms).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario:** You are the night shift nurse for Mr. Johnson, a 65-year-old post-op total knee replacement patient on a hydromorphone PCA pump. During your 2 AM rounds, you find him difficult to arouse. His respirations are slow and shallow.

**Nursing Intervention Strategy:**
1.  **Immediate Assessment (ABCs):** Gently but firmly attempt to wake him. If he does not rouse easily, **stop the PCA pump**. Assess airway (listen for sounds), breathing (count RR for 30 sec, observe chest rise, check SpO2), and circulation (check pulse, BP).
2.  **Initial Interventions:** Call his name, apply a sternal rub. If breathing is inadequate (RR < 10, SpO2 dropping), call a rapid response or code blue per hospital policy. Administer supplemental oxygen via non-rebreather mask at 15 L/min.
3.  **Pharmacologic Reversal:** Prepare naloxone as per standing order or provider instruction (typical initial dose: 0.4 mg IV push). Administer and monitor for response (increased RR, arousal) within 1-2 minutes. Be prepared to repeat doses.
4.  **Post-Intervention Care & Monitoring:** After reversal, the patient will be awake and in severe pain. Provide emotional support and explain what happened. Collaborate with the provider for an alternative pain management plan. Monitor closely for re-sedation as naloxone's effects wear off (often 30-90 minutes).

**Patient Safety and Precautions:**
*   Key Point! Never leave a sedated patient unattended. Use institutional sedation scales at regular intervals.
*   Naloxone can precipitate acute withdrawal in opioid-dependent patients (agitation, hypertension, tachycardia). Have safety precautions in place.
*   For patients on continuous infusions or PCA, ensure the "lockout interval" and dose limits are correctly programmed as a double-check.

Nursing Procedure & Medication Flow
**Naloxone (Narcan) Administration (IV Route):**
1.  Verify order or follow protocol for suspected opioid overdose.
2.  Draw up 0.4 mg (1 mL of the 0.4 mg/mL concentration) into a syringe.
3.  Administer IV push slowly over 30 seconds.
4.  If no response after 2-3 minutes, repeat dose. Doses may be repeated every 2-3 minutes up to a maximum of 10 mg.
5.  Continuous monitoring of RR, SpO2, LOC, and pain level is mandatory for at least 2 hours after administration.

A Word from Your Senior Nurse
"Managing opioid therapy is a balancing act between compassion and vigilance. We want to relieve our patients' suffering, but we must also be their guardians against harm. That slow, shallow breathing you notice during a routine check isn't just a number—it's a silent alarm. Trust your assessment skills. Acting quickly on that finding, using the ABC framework, is what saves lives. On the NCLEX and at the bedside, your number one job is always to protect the airway and ensure effective breathing. Everything else comes second."

## 핵심 개념

- **Opioid-Induced Respiratory Depression** — A potentially fatal decrease in respiratory drive and effort caused by opioid medications depressing the brainstem's respiratory center.
- **Naloxone** — A competitive opioid receptor antagonist used as an emergency treatment to reverse the effects of opioid overdose, including respiratory depression and sedation.
- **Mu-Opioid Receptor** — The primary receptor in the central nervous system where opioid analgesics like hydromorphone bind to produce pain relief, euphoria, and the adverse effect of respiratory depression.
- **Sedation Scale** — A tool (e.g., Pasero Scale) used to systematically assess a patient's level of sedation when on opioid therapy, helping to identify over-sedation before respiratory depression occurs.
- **Patient-Controlled Analgesia** — A method of pain control where the patient self-administers preset doses of analgesic medication (often opioids) via an IV pump, with safety features like a lockout interval to prevent overdose.

## 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=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)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._