# A postoperative client on a fentanyl PCA becomes minimally responsive with RR 6, SpO2 86 percent, and POSS 4. The provider order says give naloxone 0.04 to 0.4 mg IV. Which administration plan is most appropriate? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=375177&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## Question A postoperative client on a fentanyl PCA becomes minimally responsive with RR 6, SpO2 86 percent, and POSS 4. The provider order says give naloxone 0.04 to 0.4 mg IV. Which administration plan is most appropriate? ## Option 1. Stop the PCA, ensure a patent IV line, and administer the full 0.4 mg naloxone undiluted as an IV bolus over 30 seconds to ensure complete opioid antagonism and immediate restoration of respiratory drive, then monitor for recurrence of sedation since naloxone's duration is shorter than fentanyl's, believing that rapid full reversal is necessary to prevent hypoxic brain injury. 2. Stop the PCA infusion, withdraw the remaining fentanyl from the cassette, add 0.4 mg naloxone to the bag to create a combined solution, then restart the PCA at a low basal rate so that the naloxone antagonizes the fentanyl continuously and prevents further respiratory depression while maintaining analgesia. 3. Stop the PCA, stimulate the client, apply oxygen, dilute 0.4 mg naloxone in 10 mL normal saline (0.04 mg/mL), give 0.04 mg (1 mL) IV slowly every 2 to 3 minutes titrated to restored respiration and arousal without precipitating severe withdrawal or pain, and prepare for repeat dosing or naloxone infusion because fentanyl may outlast naloxone. **✔ Correct answer** 4. Delay naloxone administration and instead initiate aggressive stimulation, repositioning, and high-flow oxygen via non-rebreather mask while reassessing every 5 minutes for 30 minutes, because naloxone can cause acute withdrawal and the patient may recover spontaneously with supportive measures alone. **Correct answer: 3** ## Explanation In hospital, opioid-induced respiratory depression is reversed with low-dose titrated naloxone to restore safe respiration without precipitating severe withdrawal — abrupt full reversal can cause acute pain crisis, severe agitation, hypertension, tachycardia, vomiting, pulmonary edema, arrhythmia, and seizures. ISMP and pain society guidance: (1) stop further opioid (PCA, infusion, patch as feasible — for transdermal fentanyl, remove the patch and clean the skin), stimulate the patient, position to support airway, apply oxygen 8 to 10 L/min by face mask; (2) dilute 0.4 mg naloxone in 10 mL normal saline yielding 0.04 mg/mL; (3) administer 0.04 mg (1 mL) IV over 30 seconds, then reassess every 2 to 3 minutes; repeat in 0.04 to 0.1 mg increments until RR is at least 10 and the patient is arousable; (4) anticipate renarcotization because most opioids — especially fentanyl, methadone, sustained-release products — outlast the 30 to 90 minute action of naloxone; prepare for repeat dosing or a continuous naloxone infusion (typical: two thirds of the effective bolus dose per hour); (5) continuous monitoring of RR, SpO2, capnography, sedation, and BP for at least 4 to 6 hours after the last dose; (6) document and notify the prescriber. A full bolus, waiting, or mixing into the PCA are unsafe. ## In-depth explanation Dilute, give 0.04 mg increments slowly, watch for rebound, prepare an infusion if needed. Pushing 0.4 mg straight is the trap. ## Related questions - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=en) - [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. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=en) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. 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