# Stage 4 — Generate solutions. Select all actions appropriate for the current respiratory, potassium-infusion, and anticoagulation risks. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372859&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question Stage 4 — Generate solutions. Select all actions appropriate for the current respiratory, potassium-infusion, and anticoagulation risks. 1 Resume PCA demand dosing because there is no basal infusion and the delivered amount remains below the programmed four-hour limit, even though the family activated doses during sleep. 2 Stop PCA dosing, stay with the client, call for immediate assistance, assess and support airway and ventilation, and use protocol-directed naloxone if the response remains inadequate. 3 Stop the potassium infusion, assess and manage the painful peripheral site under policy, and ask the prescriber and pharmacist to reassess the remaining dose, concentration, and route. 4 Stop heparin, aspirin, and ticagrelor indefinitely before checking for bleeding or applying the heparin nomogram because any aPTT above the target proves major hemorrhage. 5 Verify the heparin order, pump, prior response, sample timing, and bleeding findings; obtain the due aPTT and follow the hospital nomogram for that result. 6 After stabilization, secure the PCA button for patient-only use, perform family teach-back, reassess the analgesia plan, and document and report the proxy activation according to policy. ## Explanation Appropriate actions: 2, 3, 5, and 6 Choice 2 treats the immediate ventilatory threat and escalates to protocol-directed naloxone when support is insufficient. Choice 3 stops continued tissue exposure and obtains a concentration-route plan. Choice 5 uses verified data and the actual hospital nomogram rather than a guessed adjustment. Choice 6 restores patient-only control and closes education, documentation, and reporting loops. Why 1 and 4 are unsafe The programmed PCA limit does not protect a sleeping client when another person presses the button. A slightly high aPTT does not prove major bleeding or authorize stopping every antithrombotic drug; assess the client and apply the medication-specific order and protocol. ## In-depth explanation Ventilation before pump paperwork Stop additional opioid delivery, remain at the bedside, call for help, and assess and support ventilation. Use naloxone according to protocol when clinical response remains inadequate and monitor for recurrence. Stop before relocating potassium Burning with a central-only concentration in a peripheral vein is not solved by moving the same bag. Stop it, assess and manage the site, and reassess whether more potassium is needed and how it can be given safely. Verify before heparin adjustment Review sample validity, timing, current pump rate, the actual nomogram, and bleeding findings. Then implement the instruction tied to the new valid result and schedule the required follow-up. Prevent recurrence Patient-only PCA access, teach-back, reassessment of pain control, factual documentation, and safety reporting address both individual care and the system defect. ## Clinical scenario Scenario (Stage 4 — Generate solutions) The client has probable opioid-related ventilatory impairment, a painful central-only potassium concentration running peripherally, and heparin data requiring verification. Clinical judgment target Select concurrent rescue, site protection, protocol use, education, and reporting actions. ## Key concepts - **Ventilation-focused opioid rescue** — Stopping opioid delivery, summoning help, supporting airway and breathing, assessing response, and using protocol-directed naloxone when needed to restore adequate ventilation. - **Extravasation response** — Stop the infusion, assess the site and neurovascular status, and follow the agent-specific facility protocol rather than flushing or automatically restarting the same solution elsewhere. - **Antithrombotic medication separation** — Heparin infusion changes follow its nomogram; aspirin and ticagrelor are separate therapies and are not automatically stopped because one aPTT is above target. ## Related questions - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. 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Always follow current clinical guidelines and your institution’s protocols._