# A 70-year-old client with a 75 mcg/hour fentanyl transdermal patch developed respiratory depression at home. EMS administered nasal naloxone 4 mg with restoration of breathing. On ED arrival 45 minutes later, the client is again becoming drowsy with RR 9. Which intervention does the nurse anticipate to prevent ongoing renarcotization?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375178&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 70-year-old client with a 75 mcg/hour fentanyl transdermal patch developed respiratory depression at home. EMS administered nasal naloxone 4 mg with restoration of breathing. On ED arrival 45 minutes later, the client is again becoming drowsy with RR 9. Which intervention does the nurse anticipate to prevent ongoing renarcotization?

## Option

1. Continue to monitor the patient’s respiratory rate and sedation level every 15 minutes for 4 hours without additional intervention, because the initial nasal naloxone dose has a long duration of action and the fentanyl from the patch will be absorbed slowly enough to not cause further respiratory depression.
2. Administer a repeat bolus of 0.4 mg intravenous naloxone, assess for response, and if respiratory rate improves to above 12 breaths per minute and sedation score decreases, continue to monitor for 4 hours, then discharge the patient with a home naloxone rescue kit and a plan to follow up with the primary care provider in 1 week.
3. Remove the fentanyl patch and clean residual drug from the skin, repeat IV naloxone dosing, and start a continuous IV naloxone infusion typically at two-thirds of the effective bolus dose per hour with continuous monitoring of RR, SpO2, capnography, and sedation for at least 12 to 24 hours given the depot effect of the patch. **✔ Correct answer**
4. Remove the fentanyl patch for 4 hours until the patient is fully awake and respiratory rate is above 16, then reapply the same patch and provide an order for intravenous naloxone 0.4 mg every 4 hours as needed for sedation or respiratory rate below 10, with plans to discharge the patient after 24 hours of observation if stable.

**Correct answer: 3**

## Explanation

Long-acting opioids — fentanyl transdermal patch (depot remains 12 to 24 hours after removal), methadone (half-life 15 to 60 hours), sustained-release oxycodone or morphine, and the ongoing presence of an unresolved exposure source (intact patch, illicit fentanyl analog) — outlast a single naloxone dose. Naloxone half-life is short (30 to 90 minutes), so renarcotization (return of respiratory depression) is expected. Hospital management: (1) eliminate ongoing opioid source — remove and dispose of any fentanyl patch and clean the skin to remove residual drug, stop infusions, gather history of any other opioid use; (2) repeat IV naloxone titration as in Q2; (3) initiate a continuous IV naloxone infusion typically calculated as two-thirds of the effective bolus dose given over the previous hour, with hourly reassessment and titration; (4) monitor RR, SpO2, continuous capnography, sedation (POSS), and BP for at least 12 to 24 hours after the patch removal because of depot effect; for methadone overdose monitor longer (24 to 48 hours); (5) transition to subcutaneous naloxone or extended discharge plan if applicable; (6) address pain plan because opioid abrupt cessation will cause withdrawal and pain — multimodal alternatives, slower opioid titration, addiction medicine consult if applicable; (7) document and event report. Waiting, applying a new patch, or discharging on a single nasal dose are unsafe.

## In-depth explanation

Long-acting opioid plus short-acting naloxone equals predictable renarcotization. Remove the source, repeat boluses, start an infusion, monitor for 12 to 24 hours.

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