A recent postoperative client is being transferred back to the medical-surgical unit. The client is receiving morphine through a patient-controlled analgesia (PCA) pump. The nurse notes that the client is lethargic, with a blood pressure of 118/66 and respirations of 8. What should the nurse have readily available?
Oxygen and suction equipment
Naloxone
IV fluids
Blood pressure monitor
The Correct Answer is B
Choice A reason: Oxygen and suction equipment support respiratory function but are not the priority for opioid-induced respiratory depression from morphine. Lethargy and low respiratory rate (8 breaths/min) indicate overdose, requiring naloxone to reverse opioid effects first, as hypoxia can persist without addressing the primary cause.
Choice B reason: Naloxone, an opioid antagonist, reverses morphine-induced respiratory depression and lethargy. A respiratory rate of 8 breaths/min signals overdose, risking hypoxia and brain damage. Naloxone restores normal respiration by blocking opioid receptors, making it critical to have readily available for immediate administration in this scenario.
Choice C reason: IV fluids may support blood pressure but are not the priority for opioid-induced respiratory depression. Lethargy and low respiratory rate indicate morphine toxicity, requiring naloxone to reverse effects. Fluids address secondary issues like hypovolemia, not the primary concern of respiratory compromise in this case.
Choice D reason: A blood pressure monitor is unnecessary, as the client’s blood pressure (118/66) is stable. The critical issue is respiratory depression and lethargy from morphine, requiring naloxone. Monitoring blood pressure is secondary to addressing life-threatening respiratory compromise caused by opioid overdose in this postoperative client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
No explanation
Correct Answer is ["5"]
Explanation
Step 1 is (2 grams ÷ 10 mL) Result = 0.2 grams per mL
Step 2 is (1 gram ÷ 0.2 grams per mL) Result = 5 mL
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