# A 70-year-old client receiving morphine 4 mg IV for postoperative pain becomes drowsy 30 minutes later. Vital signs show RR 8, SpO2 88% on room air, BP 96/58, HR 56, sedation scale (POSS) 4 (somnolent, minimal response to physical stimulation). Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375144&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 70-year-old client receiving morphine 4 mg IV for postoperative pain becomes drowsy 30 minutes later. Vital signs show RR 8, SpO2 88% on room air, BP 96/58, HR 56, sedation scale (POSS) 4 (somnolent, minimal response to physical stimulation). Which is the priority nursing action?

## Option

1. Stop further opioid administration, stimulate the client and apply oxygen, prepare to administer naloxone 0.04 to 0.4 mg IV in titrated doses, and call the rapid response team. **✔ Correct answer**
2. Administer supplemental oxygen via non-rebreather mask, place the client in the recovery position, monitor oxygen saturation continuously, and prepare for possible endotracheal intubation.
3. Reposition the client to a semi-Fowler's position, apply a pulse oximeter, start oxygen via nasal cannula at 2 L/min, monitor respiratory rate, and recheck vital signs in 30 minutes.
4. Notify the health care provider, prepare to administer flumazenil 0.2 mg IV push over 30 seconds, and continue to monitor vital signs every 15 minutes.

**Correct answer: 1**

## Explanation

Opioid-induced respiratory depression is the most feared adverse effect of morphine and other mu-agonists. Risk factors include older age, opioid naivete, sleep apnea, obesity, concurrent sedatives or benzodiazepines, hepatic or renal impairment, and the first 24 hours of opioid initiation or dose escalation. Standard surveillance: RR, SpO2, level of consciousness, and a sedation scale such as POSS (Pasero Opioid-induced Sedation Scale: 1=awake/alert, 2=slightly drowsy, 3=frequently drowsy/arousable/drifts off mid-conversation, 4=somnolent/minimal response). Treatment of clinically significant respiratory depression: (1) hold further opioid, (2) stimulate the patient and apply oxygen by face mask 8 to 10 L/min while preparing equipment, (3) administer naloxone 0.04 to 0.4 mg IV slowly, titrated to restore respirations and arousability without precipitating severe withdrawal or pain — repeat every 2 to 3 minutes as needed, (4) call rapid response, monitor q5 to q15 minutes given naloxone half-life is shorter than morphine; rebound respiratory depression is common, naloxone infusion may be needed, (5) document and notify prescriber. Documenting alone, giving more morphine, or restraining are unsafe.

## In-depth explanation

Stop opioid, stimulate and oxygenate, give naloxone in small titrated doses, and watch for renarcotization. POSS 4 plus RR 8 is the classic NCLEX picture for naloxone.

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