Question

A 40 yo hospitalized patient is being treated for a fractured femur and now has a PCA pump infusing an opioid. On the hourly rounds, the nurse notes the patient has a respiratory rate of 5 breaths/min. What is the nurses FIRST action?

A- assess the patient's BP and pain level
B- discontinue the opioids on the med administration record
C- document the respiratory rate in the electronic chart
D- call the emergency response team and prepare to administer naloxone

Answer 1

The first action the nurse should take is to call the emergency response team and prepare to administer naloxone. The correct answer is option D.

Step-by-step explanation:

The nurse's first action when a 40-year-old patient being treated for a fractured femur with a PCA pump infusing an opioid has a respiratory rate of 5 breaths/min should be to call the emergency response team and prepare to administer naloxone.

This is because a respiratory rate of less than 12 breaths per minute, especially as low as 5 breaths per minute. It could indicate opioid overdose, which is a life-threatening situation. Immediate intervention with naloxone is crucial because it can quickly reverse the effects of opioid overdose and restore adequate respiration.

After ensuring someone has called for emergency response, the nurse should also assess the patient's blood pressure (BP). This information can be helpful to the emergency response team upon their arrival. The nurse should then ensure that these observations, as well as actions taken, are documented in the patient's electronic chart.