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Difficulty: EasySubstance Use and Other Disorders

A practical nurse finds a client unresponsive on the floor of their room with a respiratory rate of 6 breaths per minute. A visitor in the room states, "I think they just injected a lot of heroin." Which of the following is the priority action for the nurse?

  1. Call for immediate emergency assistance and open the client's airway.Answer
  2. B
    Administer a prescribed dose of intravenous push naloxone.
  3. C
    Obtain a complete set of vital signs, including a blood glucose level.
  4. D
    Search the client's pockets and immediate area to identify the specific substance used.

Answer

The priority action is to call for immediate emergency assistance and open the client's airway.
In any emergency situation, especially a suspected opioid overdose presenting with severe respiratory depression, the nurse must follow the Airway, Breathing, and Circulation (ABC) prioritization framework. Calling for help and opening the client's airway are the most critical first steps to prevent hypoxic brain injury or death.

Step-by-Step Solution

1
Recognize the signs of a life-threatening emergency, specifically severe respiratory depression (6 breaths per minute) in a suspected opioid overdose.
The client is identified as having a compromised airway and inadequate breathing.
Identifying the immediate threat to life dictates the order of interventions.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework and Basic Life Support (BLS) principles.
Activating the emergency response system and securing the airway are prioritized over secondary assessments or out-of-scope medication administration.
BLS principles require calling for help and securing the airway before investigating the cause or obtaining full vital signs.

Key Concept

Prioritization of Care in Overdose Emergencies
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Topics

Substance Use and Other Disorders

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