# A 58-year-old client with cancer-related bone pain had oral methadone increased from 10 mg to 20 mg every 8 hours 3 days ago; fluconazole was started 2 days ago for oral candidiasis. At 2200 the client is difficult to arouse and responds only to a firm sternal rub. Respiratory rate is 7/min and shallow, oxygen saturation 86% on room air, heart rate 58/min, and blood pressure 104/60 mm Hg. Pupils are 2 mm and equal; the client moves all extremities to pain. Capillary glucose is 112 mg/dL and temperature 37.1°C (98.8°F). The cardiac monitor shows sinus bradycardia with QTc 525 ms (baseline 440 ms). Potassium is 3.4 mEq/L and magnesium 1.9 mg/dL. The client received no benzodiazepines. The pain score this morning was 4/10. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617373&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 58-year-old client with cancer-related bone pain had oral methadone increased from 10 mg to 20 mg every 8 hours 3 days ago; fluconazole was started 2 days ago for oral candidiasis. At 2200 the client is difficult to arouse and responds only to a firm sternal rub. Respiratory rate is 7/min and shallow, oxygen saturation 86% on room air, heart rate 58/min, and blood pressure 104/60 mm Hg. Pupils are 2 mm and equal; the client moves all extremities to pain. Capillary glucose is 112 mg/dL and temperature 37.1°C (98.8°F). The cardiac monitor shows sinus bradycardia with QTc 525 ms (baseline 440 ms). Potassium is 3.4 mEq/L and magnesium 1.9 mg/dL. The client received no benzodiazepines. The pain score this morning was 4/10. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Acute ischemic stroke
Methadone toxicity
Hypoactive delirium
Hypoglycemic encephalopathy

Actions to take

Select 2
Administer the prescribed IV dextrose 50%
Arrange an emergency noncontrast CT of the head
Ventilate with a bag-valve mask and oxygen
Give prescribed IV naloxone in small doses
Administer the prescribed IV flumazenil

Parameters to monitor

Select 2
Respiratory rate and sedation level
QTc interval on continuous ECG
Capillary blood glucose every 30 minutes
NIH Stroke Scale score
Pain intensity score

## Explanation

Methadone accumulates for days after a dose increase, and fluconazole inhibits its metabolism, so sedation with respirations of 7/min, pinpoint pupils, and a new QTc of 525 ms indicate methadone toxicity. The nurse supports ventilation with a bag-valve mask and gives naloxone in small titrated doses. Because methadone outlasts naloxone, respiratory rate with sedation and the QTc must be trended continuously.

## In-depth explanation

Quick answer
Methadone toxicity. Actions: ventilate with a bag-valve mask and oxygen; give prescribed IV naloxone in small doses. Monitor: respiratory rate with sedation level, and the QTc interval on continuous ECG.

Why this is correct
Methadone has a long, variable half-life, so toxicity often appears several days after a dose increase. Fluconazole inhibits CYP3A4, raising methadone levels further. The label warns of life-threatening respiratory depression and QT prolongation. Hypoventilation is the immediate threat, so ventilation comes first and naloxone is titrated to restore breathing without precipitating severe withdrawal and pain.

Easy analogy or mental picture
Methadone is a slow-burning log and naloxone a quick splash of water: the flames go down, but the log keeps smoldering and can flare again, so someone must keep watching the fire.

Memory hook
Methadone: slow in, slow out; naloxone: fast in, fast out. Breathe, reverse, re-watch.

NCLEX decision rule
For opioid-induced respiratory depression, support airway and breathing first, reverse with naloxone titrated to respirations, and monitor for recurrence longer than the antagonist lasts.

Why the other choices are wrong
Hypoglycemia is excluded by a glucose of 112 mg/dL, so dextrose and glucose checks are misdirected. Stroke is tempting in a sudden change in consciousness, but pinpoint equal pupils and movement of all extremities fit opioid toxicity, so a head CT and NIH Stroke Scale would delay reversal. Hypoactive delirium does not cause respirations of 7/min with pinpoint pupils. Flumazenil reverses benzodiazepines, which the client did not receive, and can provoke seizures. A pain score is an outdated endpoint for opioid safety; sedation and respiratory rate are the correct measures.

References
1DailyMed — Methadone hydrochloride prescribing informationBoxed warnings for life-threatening respiratory depression, QT prolongation, and CYP3A4 interactions.

## Clinical scenario

Scenario
After a methadone dose increase and a new CYP3A4 inhibitor, a client is difficult to arouse with respirations of 7/min, pinpoint pupils, oxygen saturation 86%, and a QTc of 525 ms.

## Key concepts

- **QTc prolongation** — A heart-rate-corrected QT interval above about 500 ms that raises the risk of torsades de pointes.
- **CYP3A4 inhibitor** — A drug such as fluconazole that slows hepatic metabolism of methadone and increases its level.
- **Naloxone titration** — Giving small repeated doses of naloxone to restore breathing without causing abrupt withdrawal.

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