A practical nurse (PN) is preparing to administer scheduled morning medications to a client who is postoperative. The medication administration record includes oral oxycodone for pain management, oral docusate sodium, and subcutaneous heparin. Upon entering the room, the PN observes that the client is somnolent, mumbles incoherently when stimulated, and exhibits shallow breathing. The client's vital signs are: blood pressure , heart rate , respiratory rate , and oxygen saturation on room air. Which of the following is the most appropriate action for the PN to take?
- Withhold the scheduled oral oxycodone, attempt to further stimulate the client, and immediately notify the registered nurse.Answer
- BAdminister the scheduled oral oxycodone to prevent breakthrough pain, as aggressive pain management is required postoperatively.
- CConfirm the client's identity using the room number and bed assignment, then administer the scheduled subcutaneous heparin.
- DObtain a PRN dose of intravenous (IV) push naloxone and administer it immediately to reverse the respiratory depression.
Answer
The correct action is to withhold the scheduled oral oxycodone, attempt to further stimulate the client, and immediately notify the registered nurse.
The client is exhibiting clear signs of opioid-induced respiratory depression, evidenced by a respiratory rate of , oxygen saturation of , and profound somnolence. According to the ABCs (Airway, Breathing, Circulation) of prioritization, addressing the client's respiratory status is the immediate life-saving priority. The practical nurse must withhold any further central nervous system depressants, such as oral oxycodone, attempt to arouse the client, and immediately escalate the situation to the registered nurse for advanced assessment and intervention.
Step-by-Step Solution
Key Concept
Recognizing opioid-induced respiratory depression and applying ABC prioritization within the practical nurse scope of practice.