A nurse is caring for a post-operative client in the post anesthesia care unit (PACU).

Exhibits

A nurse has assessed the postoperative client. Which of the following interventions are needed immediately?
(Select All that Apply.)

A. Give naloxone 0.2 mg IV STAT
The client has received multiple opioids (fentanyl + morphine) and is now increasingly somnolent, minimally responsive, with shallow respirations and low oxygen saturation. These are classic signs of opioid-induced respiratory depression, and naloxone (an opioid antagonist) should be administered immediately.

B. Bag-valve-mask (BVM) ventilations
The client has shallow respirations and poor oxygenation (SpO₂ dropped to 92%) and is minimally responsive. BVM is essential to maintain oxygenation and ventilation while naloxone takes effect or if apnea develops.

C. Chest compressions
There is no indication of cardiac arrest. The client still has a pulse and blood pressure, though hypotensive.

D. Defibrillation
There is no mention of a shockable rhythm (e.g., V-fib or pulseless V-tach). Defibrillation is not indicated for respiratory depression or somnolence.

E. Incentive spirometry
The client is minimally responsive and unable to cooperate with incentive spirometry. This is used post-op for alert clients to prevent atelectasis, not for unconscious or sedated patients.

F. Chest physiotherapy (CPT)
Not appropriate for this case. CPT is used for mucus clearance in conditions like COPD or pneumonia, not for opioid-induced respiratory depression.

G. Give 2 units of packed red blood cells (PRBCs)
There is no sign of active bleeding or anemia. Hemoglobin was not reported to be low, and there are no signs of hemorrhagic shock.

H. Obtain crash cart
The client is decompensating rapidly - lethargy, hypotension, and respiratory depression could progress to respiratory or cardiac arrest. Having the crash cart ready ensures that resuscitation medications and defibrillation (if needed) are available without delay.

I. Correct electrolyte imbalance(s)
There is no data provided suggesting an electrolyte imbalance. This is not a priority in the setting of opioid overdose with respiratory compromise.

J. Give morphine sulfate 2 mg IV x 1 STAT
This would worsen the client’s condition by increasing opioid load in someone already experiencing opioid toxicity. It’s absolutely contraindicated.