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Difficulty: MediumSubstance Use and Other Disorders

A young adult client with a history of opioid use disorder is brought to an outpatient clinic by a family member. The client exhibits severe lethargy, slurred speech, and a respiratory rate of 7 breaths/minute. The family member anxiously asks the practical nurse (PN), "Did my child take heroin again?" Which action should the PN take first?

  1. Vigorously stimulate the client while immediately calling for emergency medical assistance.Answer
  2. B
    Prepare to independently administer an intravenous push dose of naloxone.
  3. C
    Ask the family member, "Why do you believe that they have relapsed on heroin?"
  4. D
    Complete a full set of vital signs, including blood pressure and temperature, before notifying the registered nurse (RN).

Answer

The correct action is to vigorously stimulate the client while immediately calling for emergency medical assistance, prioritizing the client's compromised breathing over all other actions.
A respiratory rate of 7 breaths/minute indicates severe respiratory depression, a hallmark of opioid overdose. According to the ABC (Airway, Breathing, Circulation) framework, this is a life-threatening emergency. The practical nurse must prioritize basic life support by attempting to rouse the client through vigorous stimulation and immediately activating the emergency response system to secure advanced airway management and reversal agents.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has severe lethargy and a respiratory rate of 7 breaths/minute, which strongly indicates acute respiratory depression likely caused by an opioid overdose.
Recognizing life-threatening physiological cues is the first step in clinical judgment.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework.
A respiratory rate of 7 is critically low and requires immediate intervention to support breathing and prevent complete respiratory arrest.
Physiological needs related to oxygenation and ventilation always take precedence over psychosocial concerns or routine data collection.
3
Determine the appropriate action within the practical nurse (PN) scope of practice.
The PN must initiate basic life support measures, such as physical stimulation, and immediately activate the emergency response system to secure advanced care and reversal agents.
Independent administration of intravenous medications is outside the PN scope, and delaying emergency care to answer the family member or take secondary vital signs could result in a fatal outcome.

Key Concept

Prioritizing ABCs and Emergency Response in Opioid Overdose
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Topics

Substance Use and Other Disorders

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