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Soru

Zorluk: OrtaPharmacological Therapies

A licensed practical nurse is caring for a client who underwent abdominal surgery earlier in the day. The client requests a scheduled as-needed dose of oral hydromorphone, reporting incisional pain as 9 on a 0-to-10 scale. Upon data collection, the nurse observes that the client is extremely drowsy, difficult to arouse, and has a respiratory rate of 8 breaths per minute. Which action should the nurse take first?

  1. Withhold the opioid medication and immediately notify the registered nurse about the client's respiratory depression.Cevap
  2. B
    Administer the prescribed analgesic to manage the severe pain, prioritizing the client's comfort and self-reported pain level.
  3. C
    Accept a verbal order from the provider to independently administer an intravenous push of naloxone to reverse the sedation.
  4. D
    Prepare the oral dose and verify the client's identity using the bed assignment and room number to avoid delaying treatment.

Cevap

The nurse must withhold the opioid medication and immediately alert the registered nurse regarding the client's compromised respiratory status.
The client is exhibiting signs of severe central nervous system and respiratory depression, evidenced by a respiratory rate of 8 breaths per minute and difficulty arousing. These are critical adverse effects of opioid analgesics. The absolute priority for the practical nurse is to ensure client safety by utilizing the ABC (Airway, Breathing, Circulation) framework. This requires withholding any further central nervous system depressants and immediately escalating the findings to the registered nurse or healthcare provider for rapid medical intervention.

Adım Adım Çözüm

1
Assess the client's clinical presentation in relation to the requested medication.
The client has a severely depressed respiratory rate (8 breaths per minute) and altered level of consciousness (difficult to arouse).
Before administering any central nervous system depressant like hydromorphone, the nurse must ensure the client's vital signs can safely tolerate the medication.
2
Prioritize the clinical findings using the Airway, Breathing, Circulation (ABC) framework.
The compromised breathing status takes immediate precedence over the client's severe pain report.
Airway and breathing are fundamental physiological needs; failure to maintain them can lead to rapid deterioration and respiratory arrest.
3
Determine the safest and most appropriate intervention within the practical nursing scope of practice.
The nurse withholds the scheduled medication and immediately notifies the registered nurse.
The practical nurse must prevent further harm by withholding the drug and escalating the situation to the RN, who has the scope to administer intravenous push reversal agents if ordered.

Anahtar Kavram

Prioritization of airway and breathing (ABC framework) and adherence to scope of practice when managing opioid-induced respiratory depression.
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Pharmacological Therapies

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