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Difficulty: MediumPharmacological Therapies

A practical nurse (PN) is caring for a 78-year-old client who was admitted with a fractured femur and is receiving scheduled doses of oral oxycodone for pain management. During the night shift, the PN finds the client newly agitated, picking at the bedsheets, and unable to recognize family members. The client's vital signs are blood pressure 102/68 mm Hg, heart rate 94 beats/min, respiratory rate 11 breaths/min, and oxygen saturation 89% on room air. The client's family requests the next dose of pain medication to calm the client. Which action should the PN take first?

  1. Withhold the oxycodone, apply supplemental oxygen, and promptly report the findings to the registered nurse (RN).Answer
  2. B
    Administer the prescribed oxycodone to manage the pain that is likely causing the client's severe agitation.
  3. C
    Explain to the family that nighttime confusion is an expected response in older adults and administer the medication.
  4. D
    Accept a verbal order from the on-call provider to administer an intravenous push dose of lorazepam to ensure safety.

Answer

The correct action is to withhold the oxycodone, apply supplemental oxygen, and promptly report the findings to the registered nurse (RN).
The client is demonstrating signs of significant respiratory depression (11 breaths/min) and resulting hypoxia (89% oxygen saturation), which are life-threatening adverse effects of opioid analgesics like oxycodone. Acute confusion and restlessness in an older adult are frequently the primary, early signs of hypoxia. The safest and most appropriate action within the PN scope of practice is to withhold the respiratory depressant, intervene by applying oxygen to address the immediate breathing compromise, and escalate the critical situation to the RN immediately.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has a low respiratory rate (11 breaths/min), hypoxia (89% oxygen saturation), and acute neurological changes (agitation, confusion).
To identify any immediate life-threatening conditions or contraindications to scheduled medications.
2
Correlate the assessment findings with the prescribed pharmacological therapy.
The findings represent adverse effects of oxycodone (respiratory depression) and the resulting hypoxia (manifesting as acute confusion).
To determine if the medication is safe to administer or if it is contributing to the client's deterioration.
3
Determine the priority nursing intervention within the PN scope of practice.
The priority is to withhold the offending medication, support the respiratory system with oxygen, and escalate the findings to the RN.
Airway and breathing are the highest priorities. PNs must recognize critical changes, intervene safely within their scope, and communicate urgently with the supervising RN.

Key Concept

Opioid safety, recognition of hypoxia-induced delirium, and PN scope of practice.
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Topics

Pharmacological Therapies

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