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Difficulty: Very hardChemical and Other Dependencies / Substance Use Disorders

A nurse discovers a client unresponsive with severe cyanosis, pinpoint pupils, and a respiratory rate of 4 breaths/minute. An empty bottle of prescription oxycodone is found on the bedside table. The nurse immediately activates the rapid response team. Arrange the following nursing actions in the correct prioritized sequence.

  1. 1Assess the carotid pulse for up to 10 seconds.
  2. 2Open the airway using the head-tilt/chin-lift maneuver.
  3. 3Initiate rescue breathing using a bag-valve-mask (BVM) device connected to 100% oxygen.
  4. 4Administer the prescribed intravenous naloxone.
  5. 5Turn the client into a side-lying (recovery) position.

Answer

The correct sequence is to first assess the pulse, then open the airway, initiate rescue breathing, administer the naloxone, and finally place the client in the recovery position.
The correct sequence strictly adheres to the American Heart Association (AHA) Basic Life Support (BLS) guidelines and the ABCs (Airway, Breathing, Circulation) of resuscitation. After establishing unresponsiveness and calling for the rapid response team, the nurse must first assess the pulse to rule out cardiac arrest. Finding a pulse but severely inadequate breathing (4 breaths/minute) indicates acute respiratory arrest. The nurse must immediately open the airway and provide rescue breathing with a BVM device. Establishing ventilation and oxygenation is the absolute highest priority to prevent anoxic brain injury. Only after the client is being actively ventilated should the nurse administer the prescribed naloxone. Finally, because naloxone causes abrupt reversal of opioid effects and can induce acute withdrawal symptoms like vomiting, placing the spontaneously breathing client in the recovery position is critical to prevent aspiration.

Step-by-Step Solution

1
Assess the carotid pulse for up to 10 seconds.
Determines the presence of circulation.
Basic Life Support (BLS) guidelines dictate assessing circulation immediately after calling for help to differentiate between respiratory arrest and cardiac arrest.
2
Open the airway using the head-tilt/chin-lift maneuver.
Clears anatomical obstruction (the tongue) from the airway.
If a pulse is present but the patient is in respiratory failure (4 breaths/min), the airway must be opened before ventilation can be successful.
3
Initiate rescue breathing using a bag-valve-mask (BVM) device connected to 100% oxygen.
Delivers essential oxygen to the lungs and brain.
Severe hypoxia is the most immediate threat to life in an opioid overdose. Mechanical ventilation takes priority over pharmacological interventions.
4
Administer the prescribed intravenous naloxone.
Reverses the effects of the opioid toxicity.
Once the client is being oxygenated, the opioid antagonist is given to reverse the underlying cause of the respiratory depression.
5
Turn the client into a side-lying (recovery) position.
Protects the airway from aspiration.
As naloxone reverses the overdose, it often precipitates acute withdrawal symptoms, including sudden vomiting. The recovery position uses gravity to keep the airway clear.

Key Concept

Prioritization of Opioid Overdose Emergency Management (BLS and Antidote Administration)
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Topics

Chemical and Other Dependencies / Substance Use Disorders

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