Question

A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six breaths per minute. Which action should the nurse take next?

A
Administer supplemental oxygen.
B
Prepare to administer naloxone. Correct Answer (Blank)
C
Prepare for endotracheal intubation.
D
Begin cardiopulmonary resuscitation.

Answer 1

The nurse should immediately prepare to administer naloxone to reverse the effects of opioid overdose and may need to provide supplemental oxygen as supportive care. Further interventions depend on the patient's response to naloxone.

Step-by-step explanation:

The nurse should take immediate action to reverse the effects of opioid overdose, which are indicated by the patient's unresponsiveness and dangerously low respiratory rate. The priority is to prepare to administer naloxone (Narcan), an opioid antagonist that can reverse the life-threatening effects of opioid overdose. Naloxone works by quickly displacing opioids from their receptors in the brain, which can restore normal breathing in a person who is experiencing opioid-induced respiratory depression. Given the rapid progression of respiratory failure that can occur in an opioid overdose, the nurse should have naloxone readily available for administration. At the same time, monitoring vital signs and providing supplemental oxygen may be necessary as supportive care until the patient responds to naloxone. Endotracheal intubation or cardiopulmonary resuscitation may be required if the patient's condition deteriorates further.