# A nurse is assessing a patient with chronic cancer pain who has been using a patient-controlled analgesia (PCA) pump with hydromorphone for the past 48 hours. Which assessment finding would be the most concerning and require immediate intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543497  
> language: ko  
> subject: Pharmacology

## 문제

A nurse is assessing a patient with chronic cancer pain who has been using a patient-controlled analgesia (PCA) pump with hydromorphone for the past 48 hours. Which assessment finding would be the most concerning and require immediate intervention?

## 보기

1. Patient reports pain level of 4/10 on the numeric rating scale
2. PCA pump shows 15 attempts with 12 successful doses delivered in the past 4 hours
3. Patient appears drowsy but is easily aroused when spoken to
4. Patient's respiratory rate is 8 breaths per minute with shallow breathing **✔ 정답**

**정답: 4**

## 해설

A respiratory rate of 8 breaths per minute with shallow breathing indicates severe opioid-induced respiratory depression, requiring immediate intervention. Other findings like pain scores or PCA usage patterns are less urgent.

## 심화 해설

Clinical Judgment
This question assesses the Recognize Cues and Prioritize Hypotheses stages, focusing on patient safety and risk recognition. The most life-threatening complication during PCA pump use is opioid-induced respiratory depression. Compared to a normal respiratory rate (12-20 breaths/min), a rate of 8 breaths/min with shallow breathing indicates severe respiratory depression, which can lead to hypoxia, apnea, and even respiratory arrest if treatment is delayed. This is a critical cue requiring immediate reporting and intervention. The other options represent adequacy of pain control, PCA system function, or an expected side effect of opioids (drowsiness), and are not immediate life threats.

Memory Tip:
**R**espiratory **R**ate **R**ules! The top priority in opioid PCA monitoring is the **respiratory rate**. "**8** is Too Late" – a rate of 8 or less per minute is a signal for immediate intervention.

KR vs US:
While PCA use is also common in Korea, the US NGN exam particularly emphasizes the nurse's role in vigilant monitoring and independent judgment (e.g., preparing naloxone, reporting to the HCP) regarding respiratory depression. In Korean practice, it operates under a physician's order, but in the exam, the nurse's responsibility as the initial detector and first responder is the key point.

## 임상 시나리오

Clinical Practice Guide
Nursing points for patients using PCA (Patient-Controlled Analgesia):
1.  Assess respiratory rate, depth, oxygen saturation (SpO2), and level of consciousness every 1-2 hours. A respiratory rate of less than 10 breaths/min or SpO2 below 90% is a danger sign.
2.  Know the location and usage of naloxone and have it prepared.
3.  Check the PCA pump records (number of attempts/number of successful deliveries) to evaluate the adequacy of pain control and system malfunction.
4.  Educate the patient and caregiver to press the PCA button "when pain starts" and not "preventively."

Caution:
In SATA (Select All That Apply) questions asking about "nursing interventions related to PCA," monitoring respiratory status is always included. Do not judge opioid overdose based solely on the information that "the patient is drowsy but easily awakened." It must be assessed together with respiratory rate.

## 핵심 개념

- **Patient-Controlled Analgesia** — Patient-controlled analgesia. A device that allows the patient to self-administer a preset dose of analgesic (mainly opioids) intravenously by pressing a button as needed.
- **Respiratory Depression** — Respiratory depression. A condition where the respiratory rate decreases abnormally and breathing depth becomes shallow. It is the most serious side effect of opioid analgesics and can be life-threatening.
- **Opioid** — Opioids. A class of drugs that act on the central nervous system to produce powerful pain relief, but can cause side effects such as respiratory depression, nausea, constipation, and sedation (e.g., morphine, fentanyl).
- **Naloxone** — Naloxone (brand name: Narcan). An opioid receptor antagonist, it is an emergency medication that rapidly reverses respiratory depression caused by opioid overdose.
- **Sedation** — Sedation. A state of decreased consciousness where the patient is drowsy and has slowed responses. It is one of the side effects of opioids and can be a precursor to respiratory depression, requiring careful monitoring.

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