A practical nurse (PN) enters the room of a post-operative client who is receiving pain management via a patient-controlled analgesia (PCA) pump. The PN finds the client unresponsive with a respiratory rate of 6 breaths per minute. Arrange the following nursing actions in the correct order of priority from first to last.
- 1Assess the client's responsiveness using verbal and tactile stimulation.
- 2Activate the facility's rapid response team or call for immediate help.
- 3Stop the functioning of the patient-controlled analgesia (PCA) pump.
- 4Open the client's airway and prepare to assist with ventilation.
- 5Administer the prescribed opioid antagonist (naloxone).
Answer
The correct sequence is: Assess responsiveness, activate the rapid response team, stop the PCA pump, open the airway and assist with ventilation, and administer naloxone.
In the event of an acute opioid overdose characterized by unresponsiveness and severe respiratory depression, the practical nurse must follow the sequence of basic life support (BLS) integrated with immediate exposure control. The first action is to confirm unresponsiveness. Once confirmed, the nurse immediately calls for help, as managing an arrest requires a coordinated team. Next, the nurse must immediately stop the continuous administration of the opioid by turning off the PCA pump to prevent further toxicity. The nurse then focuses on the ABCs (Airway, Breathing, Circulation) by opening the airway and supporting ventilation. Finally, once life-sustaining BLS measures are established, the nurse administers the prescribed opioid antagonist, naloxone, to reverse the central nervous system depression.
Step-by-Step Solution
Key Concept
Prioritization of care for acute inpatient opioid overdose integrates Basic Life Support (BLS) sequences with stopping the exposure and providing targeted pharmacological reversal.
Estimated Time:1m 30s