# A postoperative client who received IV morphine is difficult to arouse. Respirations are 7/min and oxygen saturation is 86%. Which action should the nurse take first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394070&lang=en  
> language: en  
> subject: Medication Administration  
> category: PPT

## Question

A postoperative client who received IV morphine is difficult to arouse. Respirations are 7/min and oxygen saturation is 86%. Which action should the nurse take first?

## Option

1. Stimulate the client, support breathing, and prepare to administer naloxone. **✔ Correct answer**
2. Document the sedation as expected and reassess in 1 hour.
3. Give the next opioid dose to prevent rebound pain.
4. Place the client flat and turn off the oxygen.

**Correct answer: 1**

## Explanation

Severe sedation with respiratory depression after opioid administration is an emergency. The nurse should stimulate the client, support airway and breathing, apply oxygen as needed, and prepare for naloxone according to protocol or prescription. Delaying care or giving more opioid is unsafe.

## In-depth explanation

Clinical Judgment
Opioid safety is respiratory safety first.

Memory Tip
Low respirations after opioid: airway, breathing, naloxone.

## Clinical scenario

Clinical Practice Guide
Opioid monitoring includes sedation level, respiratory rate, oxygenation, pain control, and readiness to reverse respiratory depression.

Caution
Do not wait when respirations are severely depressed.

## Key concepts

- **Morphine** — An opioid analgesic that can depress respirations.
- **Naloxone** — An opioid antagonist used to reverse serious opioid effects.
- **Respiratory Depression** — Inadequate ventilation shown by slow or ineffective breathing.

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