A young adult client is brought to the emergency department unresponsive, with pinpoint pupils and a respiratory rate of 6 breaths per minute. The nurse suspects an acute opioid overdose resulting from high-risk substance use. Arrange the following nursing actions in the correct order of priority from first to last.
- 1Assess the client's airway patency and initiate supportive ventilation.
- 2Administer the prescribed opioid antagonist.
- 3Continuously monitor respiratory rate and level of consciousness.
- 4Provide harm-reduction education and substance use treatment resources.
Cevap
The correct sequence is to first secure the airway and ventilate, then administer the opioid antagonist, follow up with continuous monitoring for re-sedation, and finally provide harm-reduction education once the client is completely stable.
In emergency situations involving high-risk substance use, such as an opioid overdose, nursing care must be prioritized using the ABC framework (Airway, Breathing, Circulation). Airway and breathing are the immediate priority when the respiratory rate is critically low. Pharmacological intervention follows to reverse the cause. Monitoring is then essential because the reversal agent often wears off faster than the ingested opioid. Finally, health promotion and harm-reduction education are provided at the end of the sequence when the client is fully stable and ready for discharge.
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Anahtar Kavram
Prioritization in acute substance toxicity utilizing the ABCs and the nursing process.