Question

Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale?

1) Stimulate the patient.

2) Prepare to administer naloxone (Narcan).

3) Administer a dose of pain medication.

4) Notify the physician immediately.

Answer 1

The first action a nurse should take for a patient with a sedation rating of 4 is to stimulate the patient. If there is no response, the nurse should then prepare to administer naloxone (Narcan), an opiate antagonist used to reverse opioid-induced respiratory depression. Notifying the physician comes after these immediate steps.

Step-by-step explanation:

Appropriate First Action for a Sedation Rating of 4

When a patient has a score of 4 on the sedation rating scale, which indicates a potentially dangerous level of sedation and respiratory depression, the nurse's first action should be to stimulate the patient. This initial step is critical to assess the patient's level of consciousness and ability to respond. If the patient does not respond to stimulation, the next step would involve preparing to administer naloxone (Narcan). Naloxone is an opiate antagonist used to reverse the effects of opioids, particularly the life-threatening respiratory depression that can result from an overdose.

Giving a dose of pain medication would not be appropriate, as it could worsen the sedation and respiratory depression. Notifying the physician is an important step, but it should follow the immediate response of stimulation and potentially, administration of naloxone, depending on the patient's responsiveness. The collaborative approach in healthcare is essential, as highlighted by the practice of team members reviewing the key concerns for the patient's recovery and care.