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Difficulty: MediumPharmacological Therapies

A practical nurse is caring for an older adult client recovering from a total hip arthroplasty. The client is prescribed scheduled oral oxycodone for pain management. Upon entering the room to administer the morning dose, the nurse finds the client newly confused, lethargic, and exhibiting a respiratory rate of 9 breaths per minute. Which of the following is the priority action for the practical nurse to take?

  1. A
    Administer the scheduled medication to ensure the client's postoperative pain remains consistently controlled.
  2. B
    Document the confusion as a typical age-related change and reassess the client's respiratory rate in one hour.
  3. Withhold the dose of oxycodone and immediately report the clinical findings to the registered nurse.Answer
  4. D
    Prepare and administer a prescribed, as-needed intravenous push dose of naloxone to reverse the effects.

Answer

The practical nurse should withhold the dose of oxycodone and immediately report the clinical findings to the registered nurse.
The client is demonstrating signs of opioid toxicity, specifically central nervous system depression (lethargy, new confusion) and respiratory depression (a respiratory rate less than 12 breaths per minute). The safest and most appropriate action within the practical nurse scope of practice is to withhold the central nervous system depressant and immediately notify the registered nurse, who can conduct a comprehensive assessment and collaborate with the healthcare provider for emergency interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting lethargy, new-onset confusion, and a respiratory rate of 9 breaths per minute.
These are classic signs of opioid-induced respiratory depression and central nervous system depression.
2
Apply the ABCs (Airway, Breathing, Circulation) of prioritization.
The compromised breathing (bradypnea) is identified as a life-threatening priority.
Administering another dose of an opioid would further depress the respiratory drive and endanger the client's life.
3
Determine the appropriate action within the practical nurse scope of practice.
The nurse must withhold the medication and escalate the critical findings to the registered nurse.
The RN must perform a comprehensive assessment, and interventions such as administering intravenous push reversal agents are outside the scope of practice for a practical nurse.

Key Concept

Opioid toxicity monitoring and practical nurse scope of practice regarding critical client deterioration
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Topics

Pharmacological Therapies

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