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Difficulty: MediumPharmacological Therapies

A practical nurse is caring for a client who is 24 hours postoperative following an abdominal surgery. The client is prescribed oral hydromorphone every 4 hours as needed for pain. Upon entering the room to administer a requested dose, the nurse observes that the client is difficult to arouse, with a respiratory rate of 8 breaths per minute and an oxygen saturation of 88% on room air. Which action should the nurse take first?

  1. A
    Administer the hydromorphone as requested because severe postoperative pain can restrict deep breathing.
  2. B
    Bypass the electronic barcode scan to avoid waking the client fully and administer the oral dose.
  3. Withhold the hydromorphone, attempt to rouse the client, and immediately notify the registered nurse.Answer
  4. D
    Prepare and administer a prescribed dose of intravenous naloxone to reverse the respiratory depression.

Answer

The practical nurse should withhold the hydromorphone, attempt to rouse the client, and immediately notify the registered nurse.
The client is exhibiting signs of severe opioid-induced respiratory depression, as evidenced by a respiratory rate of 8 breaths per minute and hypoxia. The priority action is to ensure airway and breathing safety by withholding further central nervous system depressants, stimulating the client, and escalating the critical finding to the registered nurse for advanced intervention.

Step-by-Step Solution

1
Assess the client's vital signs and clinical presentation.
The client is difficult to arouse with a respiratory rate of 8 breaths per minute and an oxygen saturation of 88%.
To identify signs of opioid-induced respiratory depression before medication administration.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Further administration of the central nervous system depressant is withheld.
Administering an opioid would exacerbate the life-threatening respiratory depression.
3
Determine the appropriate action within the practical nurse scope of practice.
The nurse stimulates the client to encourage breathing and escalates the critical situation to the registered nurse.
Advanced interventions, such as administering intravenous naloxone, are outside the practical nurse scope of practice.

Key Concept

Opioid-Induced Respiratory Depression and PN Scope of Practice
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Topics

Pharmacological Therapies

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