Thirty minutes after receiving an IV opioid, a postoperative client is difficult to awaken. Respirations are 7/min and shallow, oxygen saturation is 84%, and the pupils are pinpoint. For each group, select all responses that apply.
Multiple Response Grouping
Choose your responses, then check the answer.
Explanation
Unresponsiveness, slow shallow breathing, and pinpoint pupils support opioid overdose. Support ventilation, summon emergency help, and give naloxone per protocol. Continue observation because opioid toxicity can recur after naloxone.
Cues: cannot awaken, slow shallow breathing, and pinpoint pupils. Actions: support breathing/emergency response and naloxone.
Why this is the best response
The cluster after an IV opioid indicates life-threatening respiratory depression, so ventilation and reversal cannot wait.
Why the alternatives do not fit
Earlier pain does not explain the current respiratory failure. Improvement after naloxone may be temporary, and induced vomiting does not reverse an injected opioid.
Sources
CDC — What to Do If You Think Someone Is Overdosing
CDC/NIOSH — Responding to a Suspected Opioid Overdose
Naloxone — An opioid antagonist used to reverse opioid-induced respiratory depression.
Recurrent toxicity — Respiratory depression can return after initial improvement, so continued monitoring is required.