A 52-year-old client is in the post-anesthesia care unit (PACU) 45 minutes after an open h… — NCLEX-RN

A $52$ -year-old client is in the post-anesthesia care unit (PACU) $45$ minutes after an open hernia repair under general anesthesia, having received intravenous fentanyl for pain control. The nurse notes the client is extremely lethargic and difficult to arouse. Vital signs are: heart rate $68 \text{ bpm}$ , blood pressure $112/70 \text{ mm Hg}$ , and respiratory rate $6 \text{ breaths/min}$ with shallow depth. An arterial blood gas (ABG) analysis reveals: pH $7.24$ , $\text{PaCO}_2$ $66 \text{ mm Hg}$ , $\text{PaO}_2$ $55 \text{ mm Hg}$ , and $\text{HCO}_3^-$ $24 \text{ mEq/L}$ . Which action should the nurse take first?

A
Apply supplemental oxygen at $10 \text{ L/min}$ via a non-rebreather mask.
B
Position the client in a high-Fowler's position to promote maximal lung expansion.
Administer the prescribed intravenous naloxone.Answer
D
Initiate vigorous tactile stimulation and reassess the respiratory rate in $5$ minutes.

Answer

Administer the prescribed intravenous naloxone.

The client is experiencing acute, uncompensated respiratory acidosis (pH

7.24

\text{PaCO}_2

66 \text{ mm Hg}

) secondary to opioid-induced hypoventilation. The severe decrease in respiratory rate (

6 \text{ breaths/min}

) and unarousable state require immediate pharmacological reversal with an opioid antagonist like naloxone to restore an adequate respiratory drive, clear the accumulated carbon dioxide, and prevent imminent respiratory arrest.

Step-by-Step Solution

Evaluate the client's clinical presentation and vital signs.

The client is extremely lethargic with a dangerously low respiratory rate of

6 \text{ breaths/min}

following fentanyl administration.

Identifying abnormal respiratory parameters is the critical first step in assessing the integrity of the airway and breathing.

Interpret the arterial blood gas (ABG) results.

The results show pH

7.24

(acidosis),

\text{PaCO}_2

66 \text{ mm Hg}

(respiratory origin), and normal

\text{HCO}_3^-

(uncompensated), confirming acute uncompensated respiratory acidosis.

Accurate ABG interpretation confirms that the hypoxemia is driven by profound hypoventilation and carbon dioxide retention.

Determine the most appropriate priority intervention based on the ABC (Airway, Breathing, Circulation) framework.

The nurse must reverse the underlying pharmacological cause of the respiratory depression.

Providing supplemental oxygen or repositioning will not restore the central respiratory drive needed to clear the excessive carbon dioxide; pharmacological reversal is mandatory.

Key Concept

Post-operative Respiratory Depression and ABG Interpretation

Estimated Time:1m 15s

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