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Difficulty: EasyHigh Risk Behaviors

A young adult client is brought to the emergency department unresponsive, with pinpoint pupils and a respiratory rate of 6 breaths per minute. The nurse suspects an acute opioid overdose resulting from high-risk substance use. Arrange the following nursing actions in the correct order of priority from first to last.

  1. 1Assess the client's airway patency and initiate supportive ventilation.
  2. 2Administer the prescribed opioid antagonist.
  3. 3Continuously monitor respiratory rate and level of consciousness.
  4. 4Provide harm-reduction education and substance use treatment resources.

Answer

The correct sequence is to first secure the airway and ventilate, then administer the opioid antagonist, follow up with continuous monitoring for re-sedation, and finally provide harm-reduction education once the client is completely stable.
In emergency situations involving high-risk substance use, such as an opioid overdose, nursing care must be prioritized using the ABC framework (Airway, Breathing, Circulation). Airway and breathing are the immediate priority when the respiratory rate is critically low. Pharmacological intervention follows to reverse the cause. Monitoring is then essential because the reversal agent often wears off faster than the ingested opioid. Finally, health promotion and harm-reduction education are provided at the end of the sequence when the client is fully stable and ready for discharge.

Step-by-Step Solution

1
Prioritize physiological needs using the ABC framework.
Airway patency and supportive ventilation are identified as the first intervention.
Without an open airway and adequate breathing, all other interventions will fail to prevent hypoxic brain injury or death.
2
Address the underlying pharmacological cause of the emergency.
Administration of the opioid antagonist is identified as the second intervention.
Reversing the opioid toxicity restores the client's spontaneous respiratory drive.
3
Evaluate the client's response to the pharmacological intervention over time.
Continuous monitoring for re-sedation is identified as the third intervention.
Naloxone has a short half-life, meaning the client can slip back into respiratory depression if the opioid outlasts the reversal agent.
4
Incorporate health promotion and prevention strategies.
Harm-reduction education is identified as the final intervention.
Psychosocial interventions and education require a conscious, cognitively intact, and physiologically stable client.

Key Concept

Prioritization in acute substance toxicity utilizing the ABCs and the nursing process.
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Topics

High Risk Behaviors

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