# A nurse is caring for an adult client 6 hours after total knee replacement who is receiving IV morphine via patient-controlled analgesia (PCA). The nurse finds the client unresponsive to verbal stimuli with respiratory rate 6/min and SpO2 84% on room air. Which actions should the nurse take immediately? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=366105&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A nurse is caring for an adult client 6 hours after total knee replacement who is receiving IV morphine via patient-controlled analgesia (PCA). The nurse finds the client unresponsive to verbal stimuli with respiratory rate 6/min and SpO2 84% on room air. Which actions should the nurse take immediately? Select all that apply.

1

Open the airway with a head-tilt chin-lift (or jaw thrust if trauma is suspected), position the client to maximize ventilation, and apply high-flow oxygen via non-rebreather mask

2

Administer naloxone IV per protocol — typically 0.04 to 0.1 mg slow push, titrated upward every 1-2 minutes until respirations improve

3

Stop the PCA pump immediately and move the PCA button out of the client's reach

4

Wait about 30 minutes to see whether the client improves before notifying the provider, because opioid effects often resolve without intervention

5

Call the rapid response or code team and begin bag-valve-mask ventilation while help arrives if respirations are inadequate

6

Continue close monitoring of respirations and sedation after naloxone because of its short half-life (30-90 min) — repeat doses or a continuous infusion may be needed if the opioid was long-acting

## Explanation

Opioid-induced respiratory depression with a respiratory rate of 6/min and SpO2 84% is an emergency. Stop the PCA and remove the button to prevent further dosing (Choice 3), open the airway and provide high-flow oxygen (Choice 1), summon the rapid response or code team and support ventilation with a bag-valve-mask when respirations are inadequate (Choice 5), and administer IV naloxone according to protocol, titrating to adequate ventilation rather than automatically seeking complete opioid reversal (Choice 2). Because naloxone may wear off before morphine, continue close respiratory and sedation monitoring and be prepared for recurrent respiratory depression, repeat dosing, or infusion as ordered (Choice 6). Waiting 30 minutes (Choice 4) is unsafe because the client is hypoventilating and hypoxemic now.

## In-depth explanation

Opioid Respiratory Depression — Action Sequence
1. Stop the opioid (PCA, infusion, oral)
2. Open airway + O2 high-flow non-rebreather
3. Call rapid response/code
4. BVM if RR < 8 or apneic
5. Naloxone titrated 0.04-0.1 mg slow IV q1-2 min
6. Continue monitoring 2+ hours after naloxone (renarcotization)

Why Titrate Naloxone?
Full-dose 0.4 mg can precipitate acute pain crisis, sympathetic surge, pulmonary edema, withdrawal. Goal: restore respirations, NOT full reversal of analgesia.

Memory Tip
"SOAR-N-Watch": Stop opioid, Open airway/O2, Assess + Activate RRT, Rescue with BVM, Naloxone titrated, Watch for renarcotization.

Caution
Long-acting opioids (extended-release, methadone, fentanyl patch) often outlast naloxone — naloxone infusion may be needed.

## Clinical scenario

Scenario
Adult, post-op day 0 total knee replacement. PCA morphine 1 mg/dose, lockout 10 min. T 36.8 · HR 58 · BP 102/64 · RR 6 · SpO2 84% RA · unresponsive to voice but withdraws to sternal rub.

Recognition (POSS scale)
POSS 5 = unresponsive to verbal/physical, sleeping deeply. RR ≤ 8 + sedation = act now.

Naloxone Dosing in Opioid-Tolerant
Start 0.04 mg slow IV; reassess at 1 min. If no response, repeat. Goal RR ≥ 10. If opioid was sustained-release, expect to need repeat doses or continuous infusion 0.4 mg/hr.

After Stabilization
- Document POSS, RR, SpO2 q15 min × 2 hr
- Provider notification, switch analgesic plan (multimodal: acetaminophen + NSAID + lower-dose opioid)
- Naloxone availability at bedside reviewed

## Key concepts

- **Naloxone (Narcan)** — Pure opioid antagonist that competitively binds mu-opioid receptors. Onset IV 1-2 min, IM/SC 2-5 min, intranasal 2-3 min. Half-life 30-90 min — shorter than most opioids, so renarcotization risk requires extended monitoring or repeat doses.
- **Pasero Opioid-induced Sedation Scale (POSS)** — Standard tool for monitoring opioid sedation in inpatients. 1 = awake/alert; 2 = drowsy, easily aroused; 3 = frequently drowsy, arousable but drifts off; 4 = somnolent, minimal response; 5 = unresponsive. Action at POSS 3 (decrease dose); STOP opioid and consider naloxone at POSS 4-5.
- **Opioid-induced respiratory depression** — Most dangerous opioid complication. Risk factors: opioid-naive, obesity, sleep apnea, concurrent CNS depressants (benzodiazepines, alcohol), renal/hepatic impairment, older age. Always monitor RR and sedation, not just SpO2 (which is a late sign with supplemental O2).

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