Question

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for pain rating 8/10. The Family member requests her father be checked immediately. On arrival to the room, the nurse finds the client difficult to arouse, with a respiration rate of 6. Which is the priority nursing action?

A. Elevate the head of the bed.
B. Administer naloxone 0.4 mg IV
C. Assess breath sounds.
D. Check vital signs and pulse oximetry

Answer 1

The priority nursing action is to administer naloxone to reverse the respiratory depression caused by hydromorphone.

Step-by-step explanation:

The priority nursing action in this situation is to administer naloxone 0.4 mg IV. Naloxone is an opioid antagonist that can reverse the respiratory depression caused by the hydromorphone, which is likely the cause of the client's difficulty in arousing and low respiration rate.

Elevating the head of the bed (option A) can help improve oxygenation and perfusion, but it will not address the client's respiratory depression. Assessing breath sounds (option C) and checking vital signs and pulse oximetry (option D) are important, but they can be done after administering naloxone to address the immediate concern of respiratory depression and difficulty in arousing.