# A postoperative client who recently received IV morphine is increasingly 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=396587&lang=en  
> language: en  
> subject: Blood/Blood Products  
> category: PPT

## Question

A postoperative client who recently received IV morphine is increasingly 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 ventilation, and prepare to administer naloxone as prescribed. **✔ Correct answer**
2. Let the client sleep because sedation is expected after surgery.
3. Give another opioid dose because pain may cause low oxygen saturation.
4. Remove oxygen to evaluate the client's baseline respiratory status.

**Correct answer: 1**

## Explanation

Severe sedation with slow respirations and low oxygen saturation suggests opioid-induced respiratory depression. The nurse should support airway and breathing, call for help, and prepare reversal therapy according to orders and protocol. Delaying action can lead to respiratory arrest.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Opioid respiratory depression.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Opioid respiratory depression, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Morphine** — An opioid analgesic that can depress respirations at excessive doses or in sensitive clients.
- **Respiratory Depression** — Inadequate breathing rate or depth that can reduce oxygenation.
- **Naloxone** — An opioid antagonist used to reverse serious opioid effects.

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