# A nurse is caring for a postoperative patient who has been using a patient-controlled analgesia (PCA) pump for pain management. 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=543498 > language: ko > subject: Pharmacology ## 문제 A nurse is caring for a postoperative patient who has been using a patient-controlled analgesia (PCA) pump for pain management. Which assessment finding would be the most concerning and require immediate intervention? ## 보기 1. Pain level of 6/10 on the numeric rating scale 2. Patient requesting additional pain medication beyond the PCA 3. Nausea and one episode of vomiting in the past 4 hours 4. Respiratory rate of 8 breaths per minute with shallow breathing **✔ 정답** **정답: 4** ## 해설 Respiratory rate of 8 breaths per minute with shallow breathing indicates opioid-induced respiratory depression, a life-threatening emergency requiring immediate intervention like stopping the PCA, administering naloxone, and providing respiratory support. Other findings (pain, nausea, medication requests) are common but less urgent. ## 심화 해설 Understanding the Priority: Airway, Breathing, Circulation When assessing a postoperative patient using a PCA pump, the nurse must apply the ABC (Airway, Breathing, Circulation) framework to identify the most life-threatening complication. While pain, nausea, and requests for additional analgesia are important comfort and safety concerns, they do not take precedence over a critical decline in respiratory function. Why Respiratory Depression is the Most Critical Finding A respiratory rate of 8 breaths per minute with shallow breathing is a sentinel sign of opioid-induced respiratory depression (OIRD). Opioids exert their analgesic effect by binding to mu-opioid receptors in the central nervous system, but this same mechanism depresses the brainstem's respiratory centers, blunting the drive to breathe. The insidious nature of OIRD makes it exceptionally dangerous; as noted in a recent case report, the subtle onset can delay detection, with a patient's condition potentially deteriorating to cardiorespiratory collapse within minutes [1]. A respiratory rate below 10-12 breaths per minute in an adult, coupled with a decreasing depth of respiration, signals that the patient is no longer effectively ventilating, leading to hypercapnia, hypoxia, and eventual respiratory arrest. This is a medical emergency requiring immediate intervention, such as stopping the PCA, administering supplemental oxygen, and preparing for the administration of an opioid antagonist like naloxone. Analyzing the Other Assessment Findings The other options represent common and expected opioid-related adverse events that, while requiring nursing action, are not immediately life-threatening. - Pain level of 6/10: Uncontrolled pain is a serious concern that requires reassessment and intervention, but it does not pose an immediate threat to the patient's survival. The priority is to stabilize a physiological crisis before addressing pain. - Requesting additional medication: This finding indicates that the current PCA settings or medication may be inadequate for the patient's analgesic needs. It requires the nurse to perform a comprehensive pain and pump assessment and collaborate with the provider, but it is not an acute, life-threatening emergency. - Nausea and vomiting: These are classic adverse effects of opioids, mediated by stimulation of the chemoreceptor trigger zone and delayed gastric emptying. While distressing and carrying a risk of aspiration or fluid imbalance, a single episode over four hours is a lower priority than a critically depressed respiratory drive. The development of novel G protein-biased mu-opioid receptor agonists, such as oliceridine, is being actively researched in clinical trials for postoperative and procedural pain to specifically reduce these gastrointestinal and respiratory adverse events while maintaining effective analgesia . The nurse's immediate clinical judgment must prioritize the assessment finding that signals a failure of a vital function. A depressed respiratory rate directly reflects a toxic opioid effect on the central nervous system and demands the most rapid and decisive intervention to prevent irreversible harm.References (research sources) - [1]Insidious opioid-induced respiratory depression following abdominal steel pipe perforation injury: A case report.Case reportZhang X, Qiao S, Pan H. (2025) · DOI: 10.1097/md.0000000000045435 ## 임상 시나리오 Opioid-Induced Respiratory Depression (OIRD) RecognitionPostoperative PCA monitoring and emergency response The most critical adverse effect of opioid-based PCA is respiratory depression. A respiratory rate of 8 breaths per minute with shallow breathing is a sentinel event requiring immediate intervention. Apply the ABC (Airway, Breathing, Circulation) framework. Sedation and bradypnea precede respiratory arrest. Continuous monitoring of respiratory rate, depth, and end-tidal CO2 (if available) is essential. CautionDo not rely solely on pulse oximetry; significant hypoventilation and hypercapnia can occur before oxygen desaturation, especially in patients receiving supplemental oxygen. Immediately stop the PCA, stimulate the patient, and prepare to administer naloxone per protocol. ## 핵심 개념 - **Opioid-Induced Respiratory Depression (OIRD)** — A life-threatening adverse effect where opioids suppress the brainstem's respiratory drive, leading to bradypnea, hypoventilation, hypercapnia, and potential respiratory arrest. - **Patient-Controlled Analgesia (PCA)** — A pain management delivery system allowing patients to self-administer preset doses of analgesic medication, commonly opioids, via an infusion pump. - **Naloxone** — An opioid antagonist used as an antidote to reverse the effects of opioid overdose, particularly respiratory depression. ## 같은 주제 문제 - [A nurse is caring for a postoperative patient using a patient-controlled analgesia (PCA) p…](https://mymerci.kr/pages/nclex_q.php?qn_id=543496) - [A nurse is assessing a patient with chronic cancer pain who has been using a patient-contr…](https://mymerci.kr/pages/nclex_q.php?qn_id=543497) - [A nurse is caring for a 65-year-old patient with chronic pain using a patient-controlled a…](https://mymerci.kr/pages/nclex_q.php?qn_id=543499) - [A nurse is caring for a postoperative patient using a patient-controlled analgesia (PCA) p…](https://mymerci.kr/pages/nclex_q.php?qn_id=543500) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._