NCLEX Question of the Day – Sunday, February 22, 2026

Today’s question targets safe opioid administration and rapid recognition of opioid-induced respiratory depression. This matters because post-op patients often receive opioids by PCA. When sedation deepens into slow, shallow breathing, minutes count. Knowing the first action protects the airway, prevents cardiac arrest, and guides the team’s next steps.

Clinical Scenario

A 74-year-old man on post-op day 1 after a left total knee arthroplasty is on a morphine PCA (1 mg demand dose, 10-minute lockout, no basal). History: COPD, obesity, and obstructive sleep apnea (uses CPAP at home). Two hours ago his vitals were normal. Now the nurse finds him difficult to arouse. Respiratory rate is 8/min and shallow. SpO2 is 88% on 2 L/min nasal cannula. Blood pressure is 132/76 mm Hg. Heart rate is 64/min. Pupils are 2 mm. Sedation score: somnolent, arouses to vigorous stimulation, quickly drifts off. Capnography (ETCO2) is 54 mm Hg. The order set includes naloxone 0.1 mg IV every 2 minutes PRN for RR less than 10 or excessive sedation (max total 0.4 mg).

The Question

Which action should the nurse take first?

Answer Choices

1. A. Administer naloxone 0.1 mg IV per PRN order and prepare to repeat every 2 minutes as needed.
2. B. Increase oxygen to 6 L/min via nasal cannula and continue to monitor.
3. C. Notify the provider and request a decrease in the PCA dose.
4. D. Encourage the patient to take deep breaths and use the incentive spirometer.

Correct Answer

A. Administer naloxone 0.1 mg IV per PRN order and prepare to repeat every 2 minutes as needed.

Detailed Rationale

Use airway, breathing, circulation (ABC) priorities. The immediate threat is hypoventilation from opioid toxicity. Clues: very low respiratory rate, somnolence, small pupils, and elevated ETCO2. Oxygen saturation is low, but the core problem is inadequate ventilation, not just oxygenation.

Naloxone is the antidote. It competitively displaces opioids from receptors and rapidly restores drive to breathe. Titrate in small IV doses (for example, 0.04–0.1 mg) to improve ventilation while avoiding abrupt, severe pain or acute withdrawal. Because a PRN order exists for this exact situation, giving naloxone now is a safe, independent nursing action within orders.

What the nurse should do, step-by-step:

• Immediately stop the PCA and ensure no visitors are pressing the button.
• Call for help and stay with the patient. Elevate the head of bed.
• Apply or maintain supplemental oxygen while preparing naloxone. If the patient worsens, be ready to use a bag-valve mask.
• Administer naloxone 0.1 mg IV. Reassess RR, level of consciousness, ETCO2, and SpO2 within 1–2 minutes. Repeat 0.1 mg doses every 2 minutes as needed up to the ordered max (for example, 0.4 mg) to reach RR ≥ 12 with adequate depth.
• Once ventilating adequately, notify the provider for a safer pain plan (for example, hold opioid, reduce dose, add multimodal non-opioid analgesia, consider CPAP use).
• Continue continuous pulse oximetry and, when available, capnography. Monitor for renarcotization because naloxone’s effect may wear off before morphine’s.
• Assess pain and hemodynamics; treat pain with non-opioids and nonpharmacologic options while avoiding oversedation.

Why this is first: Oxygen alone may raise SpO2 but can mask ongoing hypoventilation. The patient needs reversal of the cause so ventilation improves now. Calling the provider or coaching breathing delays life-saving reversal.

Why the Other Options Are Wrong

• B. Increase oxygen to 6 L/min via nasal cannula and continue to monitor. Oxygen does not fix hypoventilation. It can normalize SpO2 while CO2 rises, delaying recognition of failure. The priority is to restore the respiratory drive with naloxone. Provide oxygen as a supportive measure, but not as the only action.
• C. Notify the provider and request a decrease in the PCA dose. Dose changes are important after stabilization. Right now, the patient is at risk of respiratory arrest. Delaying antidote administration to make a phone call is unsafe. Rescue first, then report and adjust the plan.
• D. Encourage the patient to take deep breaths and use the incentive spirometer. The patient is too somnolent to follow commands. Coaching is ineffective in opioid toxicity and wastes critical time. Reverse the cause, then use pulmonary hygiene once alert.

Key Takeaways

• Excessive sedation plus RR less than 10 indicates opioid-induced respiratory depression until proven otherwise.
• Capnography (rising ETCO2) flags hypoventilation earlier than pulse oximetry.
• Titrate naloxone in small IV doses to restore ventilation, then reassess every 1–2 minutes.
• Stop the opioid source, support the airway, and anticipate renarcotization.
• High-risk features: OSA, COPD, obesity, older age, concomitant sedatives.

• On-shift mini-checklist:
  • Recognize: RR, depth, sedation level, pupils, ETCO2/SpO2.
  • Rescue: stop PCA, call for help, oxygen, naloxone titration.
  • Reassess: RR, LOC, ETCO2/SpO2 every 1–2 minutes; repeat naloxone as ordered.
  • Report and revise: notify provider, adjust analgesia, consider CPAP, add non-opioids.
  • Monitor: continuous oximetry/capnography; watch for renarcotization.

Quick Practice Extension

• Your post-op patient on a fentanyl patch becomes somnolent with RR 10/min, SpO2 92% on room air, ETCO2 50 mm Hg. What are your first three steps?
• After naloxone reverses sedation, the patient reports severe pain (9/10). What multimodal strategies can you request or implement to control pain without causing recurrent oversedation?

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com