A nurse is caring for a client who is postoperative. Exhibits Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect documentation, click on the documentation again. Temperature 37.5° C (99.5° F) Client is difficult to arouse. Respiratory rate 10/min Pulse oximetry 88% on room air (95% to 100%) Pupils are 3 mm, equal, and reactive to light. Blood pressure 99/46 mm Hg Heart rate 61/min

Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive. Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required. Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider. Other Findings: Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose. Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients. Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.