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Difficulty: Very hardSubstance Use and Other Disorders

A practical nurse working in a substance use rehabilitation facility discovers a client unresponsive on the bathroom floor. The client has a respiratory rate of 6 breaths per minute, cyanotic lips, and pinpoint pupils. A syringe is visible on the sink. Arrange the following practical nursing actions in the priority order they should be performed from first to last.

  1. 1Activate the facility's emergency medical response system.
  2. 2Palpate the carotid pulse simultaneously with breathing for up to 10 seconds.
  3. 3Initiate positive pressure ventilation using a bag-valve-mask device.
  4. 4Administer the prescribed standing order of intranasal naloxone.
  5. 5Obtain a complete set of vital signs including oxygen saturation.

Answer

The correct sequence is to first activate the emergency response system, then assess the pulse, initiate ventilation, administer naloxone, and finally obtain a complete set of vital signs.
The correct sequence of actions follows the American Heart Association (AHA) Basic Life Support (BLS) guidelines for healthcare providers managing a suspected opioid overdose. First, upon discovering an unresponsive client, the nurse must immediately activate the emergency medical response system to ensure help arrives. Second, the nurse must assess the client's breathing and palpate the carotid pulse simultaneously for 5 to 10 seconds. Third, because the client has a pulse but severe respiratory depression (6 breaths/minute), the nurse must immediately support the airway and initiate positive pressure ventilation. Fourth, once ventilation is established, the nurse administers the prescribed opioid antagonist, naloxone. Finally, after life-threatening priorities are addressed, the nurse obtains a complete set of vital signs to monitor the client's status.

Step-by-Step Solution

1
Identify the client's unresponsive state and immediately activate the emergency medical response system.
Additional healthcare personnel and life-saving equipment, such as an AED, are dispatched to the scene.
Basic Life Support (BLS) protocols dictate that activating the emergency response system is the first step upon finding an unresponsive client.
2
Assess the client's breathing and palpate the carotid pulse simultaneously for no more than 10 seconds.
The nurse determines that the client has a central pulse but is experiencing severe respiratory depression.
This brief assessment dictates the resuscitation pathway, distinguishing between the need for full cardiopulmonary resuscitation (CPR) versus respiratory support.
3
Initiate positive pressure ventilation using a bag-valve-mask device.
The client receives immediate oxygenation, addressing the life-threatening hypoxia.
Hypoxia is the primary cause of cardiac arrest in an opioid overdose. Airway and breathing must be supported immediately when a pulse is present.
4
Administer the prescribed standing order of intranasal naloxone.
The opioid antagonist begins to reverse the central nervous system and respiratory depression.
Naloxone is the specific antidote for opioid toxicity, but AHA guidelines state that its administration should never delay the initiation of rescue breathing.
5
Obtain a complete set of vital signs including oxygen saturation.
Baseline clinical data is established to monitor the client's response to the interventions.
Detailed data collection is a secondary priority performed only after all life-threatening ABC issues have been managed.

Key Concept

Prioritization of Basic Life Support (BLS) and nursing interventions in acute opioid overdose emergencies.
Estimated Time:1m 30s
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Topics

Substance Use and Other Disorders

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