Passage / Scenario

History and Physical
The client is a 42-year-old female who had a right above-the-knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1.
Nurses' Notes
1400: Started continuous morphine in the left antecubital vein peripheral intravenous line. No redness, edema, or bleeding noted at the site. Vital signs: heart rate 77 bpm, blood pressure 118/74 mmHg, respiratory rate 16.
1800: Vital signs: heart rate 79 bpm, blood pressure 114/78 mmHg, respiratory rate 14.
1900: Responded to an alarm in the room. The client is not responsive. Her respiratory rate is 5 bpm. Her heart rate is 92 bpm. Her pupils are pinpoint.
Orders
ÔÇó Admit to the surgical floor
ÔÇó Clear liquid diet, advance as tolerated
ÔÇó Continuous cardiorespiratory monitoring
ÔÇó Morphine 1 mg/hr intravenously
ÔÇó Alert surgeon to signs of bleeding or infection in the surgical site
ÔÇó Docusate sodium 240 mg orally every am
ÔÇó Naloxone 2 mg intravenously as needed for respiratory depression
ÔÇó Ibuprofen 600 mg orally every 6 hours