NCLEX-RN (Registered Nurse) Practice Exam · Question
A client receiving opioid analgesia via a patient-controlled analgesia (PCA) pump has a respiratory rate of 8 breaths/minute. The client is difficult to arouse. What is the nurse's priority action?
A respiratory rate of 8 breaths/minute and difficulty arousing indicate opioid-induced respiratory depression, a life-threatening complication. The priority is
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Question: A client receiving opioid analgesia via a patient-controlled analgesia (PCA) pump has a respiratory rate of 8 breaths/minute. The client is difficult to arouse. What is the nurse's priority action?
Answer options:
- Encourage the client to take deep breaths. ✅ Administer naloxone as per standing orders.
- Increase the client's IV fluid rate.
- Reposition the client into a semi-Fowler's position.
Correct answer: Administer naloxone as per standing orders.
Explanation: A respiratory rate of 8 breaths/minute and difficulty arousing indicate opioid-induced respiratory depression, a life-threatening complication. The priority is to administer an opioid antagonist like naloxone to reverse the effects of the opioid.
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