The patient receiving patient-controlled analgesia (PCA) with morphine is found to be sleeping deeply and minimally responsive. Which action does the nurse take first?

Determine the patient’s respiratory rate and oxygen saturation. The patient appears to be exhibiting signs of opioid overdose; however, the patient might just be sleeping deeply. Therefore, the first nursing action is to determine the patient’s respiratory rate and oxygen saturation. If it is determined the patient is experiencing respiratory depression, then the nurse can call the rapid response team, stop the PCA pump, and administer naloxone as necessary. The nurse has already attempted to wake the patient; wasting further time by applying sternal pressure is not helpful.

The patient receiving patient-controlled analgesia (PCA) with mor...

NCLEX Practice
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Pharmacological and Parenteral Therapies
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Category: Pharmacological and Parenteral Therapies
Difficulty: 6

Topics: Delegation, Prioritization and Leadership Respiratory Routes of Administration Assessment Cardiovascular Intracranial Regulation Medication and Blood Products Nursing Interventions

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