# Clinical context A 68-year-old opioid-naive postoperative client with obstructive sleep apnea and stage 3 CKD is receiving hydromorphone PCA plus scheduled gabapentin and becomes difficult to arouse with shallow respirations of 7/min, SpO2 86% on oxygen, and rising end-tidal carbon dioxide. Review the response and select the best interpretation and next plan.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522089&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

Clinical context
A 68-year-old opioid-naive postoperative client with obstructive sleep apnea and stage 3 CKD is receiving hydromorphone PCA plus scheduled gabapentin and becomes difficult to arouse with shallow respirations of 7/min, SpO2 86% on oxygen, and rising end-tidal carbon dioxide.

Review the response and select the best interpretation and next plan.

| Time | Data |
| --- | --- |
| Before rescue | Difficult to arouse; RR 7/min; SpO2 86 percent on 2 L/min; end-tidal carbon dioxide 58 mm Hg |
| Initial response after rescue | Awake to voice; RR 15/min; SpO2 96 percent; end-tidal carbon dioxide 43 mm Hg |
| Later reassessment | Increasingly somnolent; RR 9/min; SpO2 94 percent on oxygen; end-tidal carbon dioxide 52 mm Hg and rising |

Q1. How should the trend be interpreted?

The opioid emergency has permanently resolved
Respiratory depression is recurring after temporary reversal
The client is demonstrating only expected sleep

Q2. Which next plan is appropriate?

Renew emergency airway support and authorized reversal with extended monitoring
Restart the same PCA settings immediately
Discontinue ventilation monitoring because oxygen saturation is above 92 percent

## Explanation

Initial improvement followed by recurrent somnolence, bradypnea, and rising carbon dioxide indicates recurrent opioid toxicity after temporary reversal, requiring renewed rescue and prolonged monitoring.

## In-depth explanation

Quick answer
Detect recurrent respiratory depression after temporary reversal.

Why this is correct
Naloxone duration may be shorter than the opioid effect. A normal oxygen saturation on supplemental oxygen does not exclude recurrent hypoventilation.

Easy analogy or mental picture
Treat medication safety like airway triage: identify the threat, interrupt exposure, support physiology, and verify a durable response.

Memory hook
Cue, risk, action, response, recurrence check.

NCLEX decision rule
Choose the action that prevents the most immediate medication-related harm while preserving reassessment and escalation.

Why the other choices are wrong
Options that normalize deterioration, add interacting medication, or delay rescue leave the safety loop open.References
1DailyMed: Hydromorphone Hydrochloride InjectionLife-threatening respiratory depression, supportive measures, and opioid reversal
2FDA Drug Safety Communication: Gabapentinoids and Serious Breathing ProblemsAdditive sedation and respiratory depression with opioids and respiratory risk factors
3FDA: Naloxone RecommendationsRecognition of opioid overdose, naloxone administration, emergency response, repeat dosing, and continued observation

## Clinical scenario

Clinical context
A 68-year-old opioid-naive postoperative client with obstructive sleep apnea and stage 3 CKD is receiving hydromorphone PCA plus scheduled gabapentin and becomes difficult to arouse with shallow respirations of 7/min, SpO2 86% on oxygen, and rising end-tidal carbon dioxide.

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