# Stage 1 — Recognize cues. Review the 0630 handoff. Highlight the findings that require the nurse's immediate action. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617303&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question Stage 1 — Recognize cues. Review the 0630 handoff. Highlight the findings that require the nurse's immediate action. 0630 handoff. Mr. T, 64, was admitted two days ago with atrial fibrillation with rapid ventricular response and NSTEMI and had PCI with a drug-eluting stent yesterday. He receives aspirin, ticagrelor, a weight-based heparin infusion, and a morphine PCA (1 mg demand dose, 8-minute lockout, 20 mg four-hour limit, no continuous basal infusion, patient-only activation). Potassium chloride 40 mEq in 100 mL labeled CENTRAL LINE ONLY is running through a peripheral antecubital IV. At 0200 he was drowsy but conversant and rated pain 3 of 10. Now: temperature 36.9 C, heart rate 78 in sinus rhythm, respirations 10 and shallow, blood pressure 108/62 mm Hg, similar to overnight readings, and SpO2 92 percent on 2 L/min. Pain is 1 of 10. He arouses only to firm voice; pupils are 2 mm and reactive. His wife says she used the PCA while he slept, pressing the button because he looked uncomfortable. The PCA history shows 18 demands, 14 deliveries in four hours, within the programmed limit. His son relays that Mr. T complained of burning at the IV site for the past 30 minutes. An aPTT of 92 seconds at 0200 exceeded the 60 to 90 second target; the repeat is due at 0800, and there is no overt bleeding at any site. ## Explanation The findings needing immediate action are shallow respirations of 10/min, SpO2 92 percent despite 2 L/min oxygen, arousal only to firm voice compared with being conversant at 0200, the wife pressing the PCA button during sleep, and a peripheral IV site burning for 30 minutes under a 400 mEq/L potassium bag. The trap is the PCA history: 14 deliveries within the programmed limit and no basal infusion look reassuring, but a pump limit does not protect a sleeping client when someone else presses the button. The heparin data are unselectable context: the slightly high aPTT is verified against the nomogram with the due 0800 result and does not come ahead of ventilation. ## In-depth explanation Quick answer Highlight **respirations 10 and shallow**, **SpO2 92 percent on 2 L/min**, **arouses only to firm voice**, **used the PCA while he slept**, and **burning at the IV site**. Why this is correct At 0200 he was drowsy but conversant; now he needs a firm voice to arouse, breathes 10 shallow breaths per minute, and desaturates despite oxygen. That trend, plus a pain score falling to 1 of 10, signals excess opioid rather than restful sleep. Proxy activation explains how the patient-only safeguard was bypassed. Separately, a concentrated potassium solution labeled for central use is burning a peripheral vein and must be stopped and the site assessed. Easy analogy or mental picture A PCA button is like a car's brake pedal that only the driver should touch: the driver stops pressing when drowsy, which is the safety feature. When a passenger presses it for a sleeping driver, the car keeps going regardless of the speed limit set on the dashboard. Memory hook Sleeping patient + someone else's thumb = no safety net. NCLEX decision rule For a client receiving opioids, compare sedation and respiratory quality with the previous assessment; worsening arousability with slow shallow breathing takes priority over pump data, laboratory rechecks, or teaching. Why the other choices are wrong **18 demands, 14 deliveries** and **no continuous basal infusion** are tempting reassurances, but the pump limit cannot protect a client when a family member presses the button. **Drowsy but conversant** was his 0200 state, which is acceptable postoperative sedation and serves as the baseline that shows today's decline. **Heart rate 78 in sinus rhythm** reflects conversion from atrial fibrillation and is not unsafe. **Blood pressure 108/62 mm Hg** is similar to overnight readings. **No overt bleeding at any site** is reassuring context for the heparin infusion; the slightly high 0200 aPTT (not selectable) is verified against the hospital nomogram with the due 0800 result rather than prompting an unsupported dose change ahead of airway and ventilation. References 1ISMP List of High-Alert Medications in Acute Care SettingsOpioids, heparin, and concentrated potassium chloride are high-alert medications requiring safeguards 2Institute for Safe Medication PracticesPCA by proxy bypasses the patient-controlled safety feature and is associated with oversedation ## Clinical scenario Scenario (Stage 1 — Recognize cues) A client one day after PCI has a morphine PCA, a heparin infusion, and concentrated potassium running peripherally; the family reports activating the PCA during sleep. ## Key concepts - **PCA by proxy** — Activation of a patient-controlled analgesia button by anyone other than the awake, capable patient, which bypasses the built-in safety of sedation-limited self-dosing. - **Opioid-induced ventilatory impairment** — Reduced respiratory drive and depth from opioids, typically preceded by increasing sedation; pulse oximetry can lag, especially when oxygen is given. - **Concentrated potassium chloride** — A high-alert electrolyte solution; high concentrations irritate peripheral veins and can cause phlebitis or extravasation injury. ## Related questions - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. 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