# A nurse is assessing a patient who has been receiving morphine sulfate 10 mg IV every 4 hours for the past 48 hours for postoperative pain management. Which assessment finding would be the most critical indicator requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=319638 > language: ko > subject: Pharmacology ## 문제 A nurse is assessing a patient who has been receiving morphine sulfate 10 mg IV every 4 hours for the past 48 hours for postoperative pain management. Which assessment finding would be the most critical indicator requiring immediate intervention? ## 보기 1. Respiratory rate of 8 breaths per minute with shallow breathing pattern **✔ 정답** 2. Blood pressure decreased from 130/80 to 110/70 mmHg 3. Patient reports pain level of 6/10 on numeric rating scale 4. Urinary output of 200 mL in the past 8 hours **정답: 1** ## 해설 Respiratory rate of 8 breaths/min with shallow breathing indicates severe opioid-induced respiratory depression, requiring immediate intervention like naloxone. Other findings (mild hypotension, pain, urinary output) are less critical and manageable with supportive care. ## 심화 해설 Core Nursing Explanation **Key Concept Analysis**: This question assesses the nurse's ability to prioritize patient safety by recognizing the most life-threatening adverse effect of opioid analgesics. The core theme is opioid-induced respiratory depression. Morphine sulfate, a potent mu-opioid receptor agonist, depresses the central nervous system (CNS), specifically the brainstem's respiratory centers. This leads to decreased sensitivity to carbon dioxide (CO2), resulting in bradypnea (slow respiratory rate) and hypoventilation (shallow breathing). This is a Key Point! for any patient receiving opioids. **Answer Rationale**: A respiratory rate of 8 breaths per minute with a shallow pattern is a critical, life-threatening sign. The normal adult respiratory rate is 12-20 breaths per minute. This finding indicates severe respiratory depression, which can rapidly progress to respiratory arrest, hypoxia, and death. It requires immediate intervention, such as administering the opioid antagonist Naloxone (Narcan), stimulating the patient, and providing respiratory support. This is the clear priority according to the ABCs (Airway, Breathing, Circulation) of emergency care. **Distractor Analysis**: Watch out for confusion! Option ②: A blood pressure decrease from 130/80 to 110/70 mmHg represents mild hypotension, a common side effect of opioids due to vasodilation and histamine release. While it should be monitored, it is not immediately life-threatening in this range and does not supersede an airway/breathing problem. Option ③: A pain level of 6/10 indicates inadequate pain control. While important for patient comfort and recovery, it is not an immediate safety threat. The nurse should reassess the pain management plan, but this is not the priority over compromised breathing. Option ④: A urinary output of 200 mL in 8 hours indicates oliguria (output less than 0.5 mL/kg/hr). Opioids can cause urinary retention due to increased bladder sphincter tone. This requires assessment (e.g., bladder scanning) and may need catheterization, but it is not an immediate threat to life like respiratory failure. **Related Concepts**: This integrates knowledge of pharmacology (opioid mechanism), pathophysiology (CNS depression), and nursing prioritization (ABCs). Understanding the specific receptor actions of morphine (mu-agonist) and its antagonism by naloxone is crucial. Monitoring for sedation using scales like the Pasero Opioid-Induced Sedation Scale (POSS) is a key preventive nursing action. Concept Summary | Concept | Description | Nursing Implication | | --- | --- | --- | | Opioid-Induced Respiratory Depression | Life-threatening slowing and shallowing of breathing due to CNS depression. | Priority assessment. Requires naloxone and respiratory support. | | Naloxone (Narcan) | Opioid receptor antagonist. Reverses respiratory depression. | Administer for RR < 8-10/min or severe sedation. Monitor for re-sedation. | | Oliguria / Urinary Retention | Common opioid side effect. Output < 0.5 mL/kg/hr. | Assess bladder distention. May require straight catheterization. | | Opioid-Induced Sedation | Precedes respiratory depression. Use POSS scale to monitor. | Intervene at early signs (somnolence) to prevent progression. | Side-by-Side Comparison! | Opioid Adverse Effect | Typical Findings | Priority Level & Action | | --- | --- | --- | | Key Point! Respiratory Depression | RR < 10/min, shallow breathing, hypoxia, somnolence. | HIGHEST PRIORITY. Immediate: Stimulate, administer naloxone, support breathing. | | Hypotension | Drop in BP, dizziness, especially with initial doses or IV push. | Monitor. Usually managed by slowing infusion, ensuring hydration. | | Urinary Retention | Inability to void, bladder distention, discomfort. | Assess bladder scan output. May require catheterization; not immediately life-threatening. | | Constipation | Almost universal side effect due to decreased GI motility. | Preventative: Start stool softeners (e.g., docusate) and stimulant laxatives concurrently with opioids. | Anatomy, Physiology & Pharmacology Points - **Mechanism:** Morphine binds to mu-opioid receptors in the brainstem (medulla), depressing the respiratory center's response to CO2. - **Antidote:** Naloxone competitively binds opioid receptors with higher affinity, displacing morphine and reversing effects within 1-2 minutes. - **Monitoring:** Assess respiratory rate, depth, and pattern along with oxygen saturation (SpO2) and level of consciousness (LOC). Sedation often precedes respiratory depression. Memory Tips - **ABCs Rule:** Always think **A**irway, **B**reathing, **C**irculation. A breathing problem (RR of 8) always trumps a circulation problem (BP 110/70) or comfort issue (pain 6/10). - **Mnemonic for Opioid Monitoring:** "**B**reathe, **P**ee, **P**oop" – Monitor for depressed **B**reathing, **U**rinary retention, and **C**onstipation. - **Number to Remember:** Respiratory rate < 10 breaths/min is a red flag requiring immediate assessment and likely intervention. High-Frequency NCLEX Topics This is a **classic NCLEX priority question**. The exam loves to test your ability to differentiate between a concerning finding and a *life-threatening* finding in patients on opioids, sedatives, or anesthesia. Always apply the ABC framework first. You will also see questions on naloxone administration, monitoring for re-sedation, and patient/family education about opioid safety. Watch Out for Question Variations! - **Shift from Symptom to Intervention:** "The nurse notes a postoperative patient on morphine has a respiratory rate of 9/min. What is the nurse's *priority* action?" (Answer: Stimulate the patient, administer oxygen, prepare naloxone). - **Shift to Patient Education:** "When teaching a family about home administration of oral morphine, which statement by the family indicates understanding?" (Correct answer would be about watching for slow/shallow breathing, not just pain relief). - **Combined with Sedation Scale:** The question may include a POSS score of 3 (somnolent, difficult to arouse) and ask for the next action. ## 임상 시나리오 Nursing Clinical Practice Guide **Clinical Scenario:** You are the night shift nurse on a surgical unit. Your patient, Mr. Johnson, 68, is 2 days post-op from a total knee replacement. He has an order for morphine sulfate 2-4 mg IV every 2 hours PRN for severe pain. He received 4 mg 90 minutes ago. During your routine rounds, you find him snoring loudly and difficult to arouse. His oxygen saturation monitor reads 89%. **Nursing Intervention Strategy:** - **Immediate Assessment (ABCs):** Gently but firmly attempt to arouse him. If he only briefly awakens, this is a critical sign. Assess his **respiratory rate and depth**. Count for a full minute. Look for a rate < 10 and shallow, irregular breaths. Check his pulse and blood pressure. - **Immediate Actions:** - **Call for help.** Use the call bell to alert colleagues. - **Position:** Ensure patient is supine with head of bed flat if safe, to open airway. - **Stimulate:** Continue verbal and tactile stimulation ("Mr. Johnson, open your eyes!"). Rub his sternum. - **Administer Oxygen:** Apply a non-rebreather mask at 10-15 L/min to correct hypoxia. - **Prepare Naloxone:** Have another nurse draw up naloxone per protocol (e.g., 0.4 mg in 1 mL saline). - **Administer Naloxone & Monitor:** Administer naloxone IV push slowly. **Patient Safety and Precautions:** Be prepared for the patient to wake up abruptly, possibly in pain and agitated. Monitor closely for **re-sedation**, as naloxone's duration (30-90 min) is shorter than morphine's. Respiratory status must be monitored for at least 2 hours after administration. - **Post-Intervention:** Notify the physician/anesthesia provider. Document everything meticulously: pre-intervention status, interventions taken (including naloxone dose/time), patient response, and post-intervention monitoring plan. Re-evaluate the pain management plan—consider a lower opioid dose, adding a non-opioid adjuvant (e.g., acetaminophen), or switching to a patient-controlled analgesia (PCA) pump with a background infusion and lockout interval. Nursing Procedure & Medication Flow **Naloxone Administration (IV Route - Emergency):** - **Indication:** Known or suspected opioid overdose with respiratory depression (RR < 10/min) or unresponsiveness. - **Dose:** Typical initial dose is 0.4 mg to 2 mg IV. In postoperative settings, smaller incremental doses (0.1-0.2 mg) are often used to reverse respiratory depression without completely reversing analgesia. - **Administration:** Administer IV push slowly over 30-60 seconds. Titrate to effect—the goal is adequate respiration, not full arousal. - **Monitoring:** Continuous monitoring of RR, SpO2, LOC, and pain level for at least 2 hours. Have additional doses ready. A Word from Your Senior Nurse "Remember, we are the guardians at the bedside. Opioids are powerful tools for pain, but they demand our utmost vigilance. That 'snoring' or 'deep sleep' could be the first clue to respiratory depression. Never just chart a low respiratory rate and move on—assess the depth, the pattern, and the patient's arousability. Your quick thinking and adherence to the ABCs can literally save a life. On the NCLEX and in practice, your ability to prioritize the threat to a patient's life above all else is what defines a safe and competent nurse. Keep asking yourself: 'What will kill my patient first?' That's your priority." ## 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._