You are working the evening shift on a surgical
unit. You assess a client on his second postoperative day; he is receiving morphine, 2 to 4 mg/hr,
with a PCA pump. He has had 17 mg morphine
during the past 6.5 hours. During your assessment
you observe that he is nodding and unable to tell
you the day of the week, his color is pale, the vital
signs are: T-37°C, P-94, R-12, BP 144/92. What
nursing actions should you initiate to determine if
the client’s symptoms are caused from a lack of
sleep, the morphine, or hypoxemia?