A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Choice A reason: This is not the action that the nurse should implement. Determining Glasgow Coma Scale score is a method of assessing the level of consciousness and neurological function of the client, but it is not a priority intervention in this situation. The client's respiratory rate and oxygen saturation are more critical indicators of the client's condition and the need for immediate action. The nurse should assess the Glasgow Coma Scale score as part of the ongoing evaluation, but it is not the first action.

Choice B reason: This is not the action that the nurse should implement. Initiating cardiopulmonary resuscitation (CPR) is a lifesaving procedure that is performed when the client has no pulse and no breathing, but it is not indicated in this situation. The client has a respiratory rate of 4 breaths/minute, which is very low, but not absent. The client also has an oxygen saturation of 75%, which is very low, but not incompatible with life. The nurse should provide oxygen therapy and ventilatory support to the client, but not CPR.

Choice C reason: This is not the action that the nurse should implement. Preparing to assist with chest tube insertion is a procedure that is done to drain air or fluid from the pleural space and restore lung expansion, but it is not relevant in this situation. The client's respiratory depression is caused by the opioid overdose, not by a pneumothorax or a pleural effusion. The nurse should monitor the client's chest x-ray and lung sounds, but not prepare for chest tube insertion.

Choice D reason: This is the action that the nurse should implement. Administering a second dose of naloxone is the most appropriate and effective intervention in this situation. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression, sedation, and hypotension. However, naloxone has a shorter duration of action than most opioids, and it may require repeated doses to maintain the reversal. The nurse should administer a second dose of naloxone if the client's respiratory rate and oxygen saturation do not improve or worsen after the first dose. The nurse should also monitor the client for signs of opioid withdrawal, such as agitation, nausea, or pain.

Choice A reason: A yellow skin color may indicate jaundice, which is a sign of liver damage. Acetaminophen can cause liver toxicity, especially in high doses or with chronic use. The nurse should report this finding to the healthcare provider as soon as possible, as it may require further evaluation and treatment.

Choice B reason: Checking the client's capillary glucose level is not relevant to the finding of yellow skin color. Although diabetes can cause skin changes, such as dryness or infections, it does not cause jaundice. The nurse should focus on the potential liver problem rather than the blood sugar level.

Choice C reason: Using a pulse oximeter to assess oxygen saturation is not helpful in this situation. A low oxygen saturation may indicate hypoxia, which can affect various organs, but it does not cause jaundice. The nurse should monitor the client's respiratory status, but it is not the priority action in response to the yellow skin color.

Choice D reason: Advising the client to reduce the medication dose is not appropriate without consulting the healthcare provider. The client may need acetaminophen for pain relief, and reducing the dose may not be enough to prevent liver damage. The nurse should not make any changes to the medication regimen without the provider's order.