Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?

Choice A reason: Immediate intubation is premature without first reversing opioid-induced respiratory depression with naloxone. Morphine’s rapid onset of lethargy and shallow breathing (7 breaths/min) indicates overdose, reversible by naloxone. Intubation is invasive and reserved for non-responsive cases, risking unnecessary complications when reversal is feasible, delaying targeted treatment in this acute scenario.

Choice B reason: Administering naloxone is the priority for opioid overdose, as evidenced by lethargy and respiratory depression (7 breaths/min) post-morphine. Naloxone, an opioid antagonist, rapidly reverses these life-threatening effects, restoring breathing and consciousness. Prompt administration is critical in older adults, who are more sensitive to opioids, ensuring patient safety and preventing hypoxia or death.

Choice C reason: Observing for opioid tolerance is inappropriate in this acute situation. Lethargy and shallow breathing indicate overdose, not tolerance, requiring immediate naloxone. Monitoring tolerance delays critical intervention, risking prolonged hypoxia, brain damage, or death, especially in an elderly patient with increased opioid sensitivity post-surgery, where respiratory depression is life-threatening.

Choice D reason: Assessing pain level is irrelevant when the patient exhibits opioid overdose symptoms like lethargy and respiratory depression. Pain assessment is secondary to reversing life-threatening respiratory compromise with naloxone. Delaying intervention for pain evaluation risks patient deterioration, as immediate action is needed to restore breathing and stabilize the patient post-morphine administration.

Choice A reason: Documenting the time of body transfer and destination ensures accurate tracking of the deceased, maintaining chain of custody and compliance with legal and hospital protocols. This information supports coordination with morgue or funeral services, preventing errors in body handling and ensuring respectful, organized end-of-life care per regulatory standards.

Choice B reason: Special preparations, like cleaning or cultural rituals, must be documented to reflect respectful care aligned with patient or family wishes. This ensures continuity of care, legal compliance, and sensitivity to cultural or religious practices, preventing oversight of specific requests and supporting dignified handling of the deceased in medical records.

Choice C reason: Time and date of death are critical for legal and medical documentation, establishing the official record required for death certificates and hospital reporting. Accurate recording ensures compliance with regulations, supports family closure, and prevents discrepancies in legal or insurance processes, making it essential in end-of-life care documentation.

Choice D reason: Location of body identification tags is documented to ensure proper identification, preventing errors during transfer or postmortem procedures. This complies with hospital policies and legal standards, ensuring traceability and respect for the deceased. Accurate tagging documentation supports safe, organized handling, critical for ethical end-of-life care management.

Choice E reason: Reason for death may be noted by physicians but is not typically required in nursing end-of-life documentation unless specified. Nurses focus on procedural details like time of death or body preparation. Including this risks role confusion, as determining cause is a medical responsibility, potentially leading to inaccurate or incomplete nursing records.