A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?

Rationale for Correct Choices

• Opioid intoxication: The client’s shallow respirations, bradycardia, hypotension, slurred speech, and pinpoint pupils are classic signs of opioid overdose. The history of oxycodone use and recent psychosocial distress further support this diagnosis. Central nervous system depression from opioids suppresses respiratory drive and leads to decreased level of consciousness and low oxygen levels.

• Obtain a prescription for naloxone: Naloxone is a pure opioid antagonist that reverses respiratory and neurologic depression caused by opioid toxicity. Its rapid onset can restore breathing and consciousness, though repeated dosing may be necessary due to its short duration of action compared to most opioids.

• Prepare to initiate mechanical ventilation: The client’s respiratory rate of 10/min and oxygen saturation of 90% indicate inadequate ventilation. Mechanical ventilation may be required to maintain oxygenation and carbon dioxide elimination until the opioid’s effects subside or naloxone takes full effect.

• Respiratory rate: Monitoring respiratory rate allows evaluation of the client’s recovery and response to naloxone. Respiratory depression is the leading cause of death in opioid overdose, so continuous observation ensures early detection of deterioration or recurrence of hypoventilation as naloxone wears off.

• Pupillary reaction: Pinpoint pupils are a key diagnostic indicator of opioid intoxication. Assessing pupil size and reactivity helps determine neurologic improvement following reversal therapy. Dilation of pupils after naloxone administration signifies recovery from opioid-induced central nervous system depression.

Rationale for Incorrect Choices

• Stimulant intoxication: Stimulant toxicity causes symptoms such as tachycardia, hypertension, hyperreflexia, and dilated pupils, which contrast with the bradycardia, hypotension, and miosis seen in this client. The assessment findings are inconsistent with stimulant use.

• Alcohol intoxication: While alcohol can cause CNS depression, it does not typically produce pinpoint pupils. The presence of severe respiratory depression, bradycardia, and low blood pressure more strongly indicates opioid overdose rather than alcohol toxicity.

• Opioid withdrawal: Withdrawal symptoms include tachycardia, hypertension, restlessness, and hyperreflexia—not CNS or respiratory depression. The client’s vital signs and presentation do not align with withdrawal.

• Anticipate administering clonidine: Clonidine is used to manage opioid withdrawal symptoms, not overdose. In this scenario, the priority is reversing respiratory depression, not mitigating withdrawal discomfort.

• Collect a blood sample for ethanol level: While alcohol use disorder is part of the history, current findings point to opioid intoxication. Measuring ethanol level would not guide immediate life-saving interventions.

• Obtain prescription for restraints: The client is sedated and hypoventilating, not agitated or combative, so restraints are unnecessary and potentially harmful. The priority is airway and breathing support, not behavioral control.

• Ethanol level: Monitoring ethanol level is not relevant in an opioid overdose and would not help assess respiratory or neurologic recovery. The focus should remain on parameters directly affected by opioids.

• Hyperreflexia: Opioid toxicity causes depressed reflexes, not heightened reflexes. Monitoring hyperreflexia would not provide meaningful information about the client’s progress.

• Cardiac arrhythmias: While opioids can depress cardiac function, arrhythmias are not a primary concern in opioid intoxication. Respiratory and neurologic parameters provide more critical indicators of client improvement.

Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.

B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.

C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.

D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.

E. A single blood administration set should not be used for more than 4 hours total due to the risk of bacterial growth. More importantly, running 2 units over a single 4 hour window would mean infusing the blood far too quickly for an older adult, drastically increasing their risk of volume overload. Each unit should be scheduled separately with a careful assessment in between.