A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago.
The client has a respiratory rate of 10/min.
The nurse should prepare to administer which of the following medications? .

The correct answer is choice d. Determine any physical signs of injury.

Choice A rationale:

Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.

Choice B rationale:

Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.

Choice C rationale:

Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.

Choice D rationale:

Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.

Choice A rationale:

Diazepam (Valium) is not the correct choice in this situation. Diazepam is a sedative and muscle relaxant but would not address the respiratory depression caused by hydromorphone. The client's respiratory rate of 10/min indicates a potential opioid overdose, and the appropriate intervention is to administer naloxone to reverse the opioid effects.

Choice B rationale:

Acetaminophen (Tylenol) is not the correct choice in this scenario. Acetaminophen is a pain reliever and fever reducer but would not address the respiratory depression caused by hydromorphone. The priority is to address the respiratory depression promptly with naloxone.

Choice C rationale:

Ibuprofen (Advil) is not the correct choice in this situation. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation but is not appropriate for reversing opioid-induced respiratory depression. Naloxone is the drug of choice to reverse opioid overdose in this case.

Choice D rationale:

Naloxone (Narcan) is the correct choice. Naloxone is an opioid receptor antagonist used to reverse the effects of opioid overdose, including respiratory depression. Given the client's low respiratory rate, naloxone should be administered promptly to counteract the effects of hydromorphone. This is the most appropriate and potentially life-saving intervention for this client.