A triage nurse in the emergency department receives a 26-year-old client who was found unresponsive in a public restroom. The client presents with pinpoint pupils, perioral cyanosis, and a respiratory rate of 5 breaths per minute. A used syringe is visible in the client's pocket. Arrange the following nursing actions in the correct sequential order of priority from first to last.
- 1Initiate manual ventilation using a bag-valve-mask device.
- 2Administer the prescribed dose of intravenous naloxone.
- 3Place the client in a lateral recovery position.
- 4Assess for manifestations of acute opioid withdrawal.
- 5Provide education on safe injection practices and dispense a take-home naloxone kit.
Answer
The correct sequence is to first initiate manual ventilation, followed by administering intravenous naloxone, placing the client in a lateral recovery position, assessing for acute opioid withdrawal, and finally providing harm reduction education.
The correct sequence strictly adheres to the nursing process and the ABCs (Airway, Breathing, Circulation) framework. Manual ventilation addresses the immediate respiratory failure (Breathing). Naloxone administration directly counteracts the pharmacological cause of the respiratory depression. Positioning the client laterally is an anticipatory safety measure to protect the airway from aspiration, a common complication of naloxone-induced emesis. Once stable, the nurse monitors for the adverse effects of reversal (acute withdrawal). Finally, secondary prevention via harm reduction education is provided when the client is fully alert and stable.
Step-by-Step Solution
Key Concept
Sequential prioritization in acute intoxication emphasizing ABCs, airway protection, and subsequent harm reduction.