A patient is receiving an opioid via a PCA pump as part of his postoperative pain management program. During rounds, the nurse finds him unresponsive, with respirations of 8 breaths/min and blood pressure of 102/58 mm Hg. After stopping the opioid infusion, what should the nurse do next?
Notify the charge nurse.
Draw arterial blood gases.
Administer an opiate antagonist per standing orders.
Perform a thorough assessment, including mental status examination.
The Correct Answer is C
Opioid therapy via PCA (patient-controlled analgesia) is effective for postoperative pain, but overdose or accumulation can cause life-threatening respiratory depression. When a patient is found unresponsive with shallow respirations, the immediate priority is to reverse the opioid’s effects with an antagonist such as naloxone. Rapid intervention can prevent respiratory arrest and stabilize the patient before additional assessments or notifications are made.
Rationale for correct answer:
C. Administer an opiate antagonist per standing orders:
Naloxone is the antidote for opioid-induced respiratory depression. Given this patient’s unresponsiveness and low respiratory rate, reversal must occur immediately to restore adequate ventilation and prevent further complications.
Rationale for incorrect answers:
A. Notify the charge nurse:
While communication is important, notifying others delays lifesaving intervention. The nurse must act first to stabilize the patient.
B. Draw arterial blood gases:
ABG testing can help determine the extent of respiratory compromise, but it is a diagnostic step, not a priority in an emergency. Immediate reversal with naloxone takes precedence.
D. Perform a thorough assessment, including mental status examination:
A full assessment is important, but not before addressing the acute emergency of respiratory depression. Stabilization comes first, then further assessment.
Take-home points:
- Naloxone is the antidote for opioid-induced respiratory depression and must be administered immediately when a patient is unresponsive and hypoventilating.
- In emergencies, airway and breathing stabilization come before notification and diagnostics.
- Nurses must recognize signs of opioid toxicity early and act rapidly to prevent respiratory arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Opioid therapy via PCA (patient-controlled analgesia) is effective for postoperative pain, but overdose or accumulation can cause life-threatening respiratory depression. When a patient is found unresponsive with shallow respirations, the immediate priority is to reverse the opioid’s effects with an antagonist such as naloxone. Rapid intervention can prevent respiratory arrest and stabilize the patient before additional assessments or notifications are made.
Rationale for correct answer:
C. Administer an opiate antagonist per standing orders:
Naloxone is the antidote for opioid-induced respiratory depression. Given this patient’s unresponsiveness and low respiratory rate, reversal must occur immediately to restore adequate ventilation and prevent further complications.
Rationale for incorrect answers:
A. Notify the charge nurse:
While communication is important, notifying others delays lifesaving intervention. The nurse must act first to stabilize the patient.
B. Draw arterial blood gases:
ABG testing can help determine the extent of respiratory compromise, but it is a diagnostic step, not a priority in an emergency. Immediate reversal with naloxone takes precedence.
D. Perform a thorough assessment, including mental status examination:
A full assessment is important, but not before addressing the acute emergency of respiratory depression. Stabilization comes first, then further assessment.
Take-home points:
- Naloxone is the antidote for opioid-induced respiratory depression and must be administered immediately when a patient is unresponsive and hypoventilating.
- In emergencies, airway and breathing stabilization come before notification and diagnostics.
- Nurses must recognize signs of opioid toxicity early and act rapidly to prevent respiratory arrest.
Correct Answer is A
Explanation
Morphine and other opioids can cause serious adverse effects when overdosed, including respiratory depression, bradycardia, hypotension, and pinpoint pupils. These are classic signs of opioid toxicity, and prompt reversal is critical to prevent respiratory and cardiac arrest. The antidote is naloxone (Narcan), an opioid receptor antagonist.
Rationale for correct answer:
A. Naloxone (Narcan): Naloxone binds to opioid receptors and displaces morphine, reversing respiratory depression, bradycardia, and CNS depression within minutes. It is the life-saving antidote in cases of opioid overdose.
Rationale for incorrect answers:
B. Meloxicam (Mobic): This is a nonsteroidal anti-inflammatory drug (NSAID) used for arthritis pain. It does not reverse opioid toxicity.
C. Pentazocine (Talwin): A mixed agonist–antagonist opioid. While it has some antagonistic activity, it is not appropriate for treating life-threatening respiratory depression.
D. Propoxyphene (Darvon): A weak opioid analgesic (now largely discontinued due to toxicity). It would worsen opioid overdose rather than treat it.
Take-home points:
- Naloxone is the emergency antidote for opioid overdose.
- Classic signs of opioid toxicity: respiratory depression, bradycardia, pinpoint pupils, cold/clammy skin.
- Prompt reversal prevents respiratory and cardiac arrest in opioid emergencies.
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