Examkin

Question

Difficulty: HardChemical and Other Dependencies / Substance Use Disorders

A nurse enters the room of a client with a history of severe opioid use disorder and finds the client unresponsive, cyanotic, and exhibiting a respiratory rate of 4 breaths/min with pinpoint pupils. Arrange the following nursing interventions in the correct order of priority, from first to last.

  1. 1Activate the facility's rapid response team and request the emergency cart.
  2. 2Establish a patent airway using a head-tilt/chin-lift maneuver.
  3. 3Initiate rescue breathing using a bag-valve-mask (BVM) device with 100% oxygen.
  4. 4Administer the prescribed dose of intravenous naloxone.
  5. 5Reassess the client's respiratory rate, oxygen saturation, and level of consciousness.

Answer

The correct prioritization sequence is: Activate the rapid response team -> Establish a patent airway -> Initiate rescue breathing with a BVM -> Administer intravenous naloxone -> Reassess the client's status.
The correct sequence strictly adheres to the American Heart Association (AHA) Basic Life Support (BLS) and prioritizing principles (ABCs). Upon discovering an unresponsive client, the nurse must first call for help. Next, physical airway patency must be established, immediately followed by rescue breathing to treat the severe hypoxia caused by the respiratory rate of 4. Only after oxygenation is supported should the nurse administer the pharmacological reversal agent (naloxone). Finally, because naloxone has a short half-life, continuous reassessment is necessary to detect recurrent respiratory depression.

Step-by-Step Solution

1
Activate the facility's rapid response team and request the emergency cart.
Additional clinical support and necessary resuscitation equipment are mobilized.
Basic Life Support (BLS) guidelines dictate that recognizing unresponsiveness must be immediately followed by calling for help before initiating time-intensive physical interventions.
2
Establish a patent airway using a head-tilt/chin-lift maneuver.
The airway is opened, lifting the tongue away from the posterior pharynx.
A patent airway is an absolute prerequisite for effective ventilation and oxygenation.
3
Initiate rescue breathing using a bag-valve-mask (BVM) device with 100% oxygen.
Oxygen is delivered to the client's lungs, correcting severe hypoxia.
The client's respiratory rate of 4 breaths/min is inadequate to sustain life. Immediate mechanical ventilation prevents progression to cardiac arrest.
4
Administer the prescribed dose of intravenous naloxone.
The opioid receptor antagonist begins to reverse the central nervous system and respiratory depression.
While naloxone treats the root cause, preparing and administering the medication takes time; the brain must be oxygenated manually while the drug is given.
5
Reassess the client's respiratory rate, oxygen saturation, and level of consciousness.
The nurse evaluates the effectiveness of the naloxone and the need for further intervention.
Naloxone's duration of action is short (approximately 30 to 90 minutes). The opioid effect may outlast the reversal agent, causing the client to slip back into respiratory depression.

Key Concept

Prioritization of care in opioid overdose emergencies using Basic Life Support (BLS) and Airway, Breathing, Circulation (ABC) principles.
Rate this question

Topics

Chemical and Other Dependencies / Substance Use Disorders

More questions from this topic