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Zorluk: KolayPharmacological and Parenteral Therapies

A nurse is caring for a client who recently received an intravenous dose of morphine for severe postoperative pain. During the reassessment, the nurse notes that the client is difficult to arouse, has pinpoint pupils, and has a respiratory rate of 8 breaths per minute. Which of the following actions should the nurse take first?

  1. Prepare to administer the prescribed naloxone.Cevap
  2. B
    Perform a pain assessment to evaluate the effectiveness of the medication.
  3. C
    Delegate an unlicensed assistive personnel (UAP) to monitor the client's vital signs.
  4. D
    Place the client in a supine position with the legs elevated to promote circulation.

Cevap

The priority action is to prepare to administer the prescribed naloxone to reverse the opioid toxicity.
The client is exhibiting the classic triad of opioid toxicity: respiratory depression, pinpoint pupils, and altered level of consciousness. A respiratory rate of 8 breaths per minute is dangerously low and compromises the client's breathing. According to the ABCs (Airway, Breathing, Circulation) framework, addressing this respiratory failure is the immediate priority. Naloxone is the specific opioid antagonist that quickly reverses these life-threatening effects.

Adım Adım Çözüm

1
Assess the client's clinical presentation.
The client has a respiratory rate of 8 breaths per minute, pinpoint pupils, and altered mental status.
Identifying these findings confirms the classic triad of opioid toxicity.
2
Apply a prioritization framework.
Using the ABCs (Airway, Breathing, Circulation), the severe respiratory depression is identified as the most critical and immediate threat to the client's life.
Life-threatening physiological needs must be addressed before secondary assessments or interventions.
3
Determine the appropriate pharmacological intervention.
Naloxone is identified as the required antidote.
Naloxone displaces opioids from receptor sites, rapidly reversing respiratory depression.

Anahtar Kavram

Opioid Toxicity and Pharmacological Reversal
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Konular

Pharmacological and Parenteral Therapies

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