A client is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump f… — NCLEX-RN

A client is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump following a bowel resection. During hourly rounds, the nurse notes the client has a respiratory rate of $8 \text{ breaths/minute}$ , pinpoint pupils, and is unresponsive to physical stimulation. The nurse immediately stops the PCA pump, calls for assistance, and receives a verbal prescription for naloxone $0.4 \text{ mg}$ IV stat. Which action by the nurse demonstrates the safest administration technique for this medication?

Dilute the medication in $9 \text{ mL}$ of normal saline and administer it incrementally over $2$ to $3 \text{ minutes}$ .Answer
B
Administer the medication rapidly over $10$ to $15 \text{ seconds}$ to immediately reverse the life-threatening respiratory depression.
C
Administer the medication directly into the Y-site of the dedicated patient-controlled analgesia (PCA) tubing.
D
Delay administration to attempt vigorously stimulating the client by applying a sternal rub.

Answer

The safest administration technique is to dilute the naloxone in

9 \text{ mL}

of normal saline and administer it incrementally over

2

3 \text{ minutes}

The standard of care for administering naloxone to a client with opioid-induced respiratory depression who is receiving pain management is to administer it slowly. Diluting an ampule of naloxone (

0.4 \text{ mg}

1 \text{ mL}

) with

9 \text{ mL}

of normal saline yields a concentration of

0.04 \text{ mg/mL}

. This allows the nurse to slowly titrate the medication (e.g.,

1

2 \text{ mL}

per minute) until the client's respiratory rate improves. This controlled reversal prevents acute opioid withdrawal, sudden excruciating pain, and sympathetic nervous system surges that can cause pulmonary edema or arrhythmias.

Step-by-Step Solution

Assess the client's condition and recognize signs of severe opioid toxicity.

Identified respiratory rate of

8 \text{ breaths/minute}

, pinpoint pupils, and unresponsiveness.

Early recognition of life-threatening respiratory depression dictates immediate intervention.

Identify the risks associated with the administration of the prescribed antidote (naloxone).

Recognized that rapid administration can cause acute withdrawal, severe pain, and cardiovascular collapse.

Naloxone displaces opioids from receptors instantly; if done too rapidly, the sudden reversal causes a massive sympathetic nervous system response.

Determine the safest preparation and administration rate.

Dilute the

0.4 \text{ mg}

dose in

9 \text{ mL}

of normal saline (creating a

0.04 \text{ mg/mL}

concentration) and push slowly.

Titrating the dose incrementally allows the nurse to reverse the respiratory depression without completely reversing the analgesic effects.

Ensure a safe route of administration.

Avoid pushing the medication through the opioid-primed PCA tubing.

Pushing through the PCA tubing would flush a bolus of concentrated morphine into the client, worsening the toxicity.

Key Concept

Safe administration of opioid antagonists and management of patient-controlled analgesia (PCA) complications.

Estimated Time:1m 30s

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