A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home.
Which of the following actions should the nurse take?

The correct answer is A. Increased pain.

Choice A reason: Naloxone is an opioid antagonist that, when administered, reverses the effects of opioids. Since opioids provide analgesia, their reversal will lead to the return of pain sensation. The normal pain response varies widely among individuals and depends on the type and amount of opioid the patient received, as well as their pain threshold and tolerance.

Choice B reason: Somnolence, or drowsiness, is a common effect of opioid administration. Naloxone works by displacing opioids from their receptors, which should counteract the sedative effects of opioids and reduce somnolence. Therefore, after naloxone administration, the nurse should not expect somnolence as a finding.

Choice C reason: Hyperglycemia, or high blood sugar, is not a direct effect of naloxone administration. While some studies suggest that naloxone may affect blood glucose levels under certain conditions, such as in the case of tramadol overdose, it does not typically cause hyperglycemia. Normal blood glucose levels range from 70 to 99 mg/dL fasting, and up to 140 mg/dL two hours after eating.

Choice D reason: Hypoventilation, or reduced breathing rate and depth, is caused by opioid administration. Naloxone’s role is to reverse this effect, restoring normal breathing rates. The normal respiratory rate for a healthy adult at rest is 12 to 20 breaths per minute.

Choice A rationale:

Providing a verbal report of the client's condition to the paramedic performing the transfer violates the client's confidentiality. Protected health information should not be disclosed verbally to individuals who do not have a need to know. Confidentiality must be maintained during all stages of care, including transfers.

Choice B rationale:

Faxing the client's name and identifiable information to the rehabilitation facility is not a secure method of transmitting sensitive health information. Faxed documents can be intercepted, compromising the client's confidentiality. Secure electronic methods or encrypted communication should be used for transmitting such information.

Choice C rationale:

Emailing the client's health information to the facility in an unencrypted file is also insecure and violates the client's confidentiality. Unencrypted emails can be intercepted and read by unauthorized individuals. Protected health information should be transmitted using secure, encrypted methods to maintain confidentiality.

Choice D rationale:

Discussing the client's response to the transfer with another staff nurse is inappropriate and breaches confidentiality. Sharing patient information, even within the healthcare team, should only be done on a need-to-know basis and in a secure, private setting.