Question

A patient who yesterday had abdominal surgery has been receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse assesses the patient and notes that the patient's pupils are constricted and that the patient is difficult to arouse. The patient's heart rate is normal, the respiratory rate is 8 breaths per minute, and the blood pressure is low. What action should the nurse take?

Select one:
a. Discuss possible opiate addiction with the patient's provider and document the patient's reaction.
b. Encourage the patient to get up to the bathroom and walk to increase alertness.
c. Document the effectiveness of the analgesia in the patient's chart and reduce the dosage of the PCA.
d. Turn off the PCA, administer oxygen, prepare to administer naloxone and possibly ventilation support.

Answer 1

The appropriate action is to turn off the PCA, administer oxygen, and prepare to provide naloxone and possible ventilation support to the patient with signs of morphine overdose.

Step-by-step explanation:

A patient who had abdominal surgery and has been receiving morphine via a patient-controlled analgesia (PCA) pump is showing signs of potential morphine overdose. The signs include constricted pupils, difficulty to arouse, normal heart rate, respiratory rate of 8 breaths per minute, and low blood pressure.

The appropriate action for the nurse to take is to turn off the PCA administer oxygen, prepare to administer naloxone, and possibly provide ventilation support. This is because naloxone is an opiate antagonist that can reverse the effects of opioids like morphine, especially the life-threatening respiratory depression.