A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

• Decreased respiratory effort, bilateral crackles: Reduced respiratory effort following opioid administration suggests opioid-induced respiratory depression. Crackles may indicate early airway compromise due to poor ventilation or fluid accumulation, requiring immediate intervention to support breathing.
• Somnolent: Somnolence beyond expected postoperative drowsiness, especially in combination with other signs of opioid overdose, indicates central nervous system depression. The client is difficult to arouse, raising concern for airway and breathing compromise.
• Pinpoint pupils: Pinpoint pupils are a hallmark sign of opioid toxicity. In the setting of recent morphine administration and accompanying respiratory depression, this finding confirms that opioid overdose is likely occurring and must be treated promptly.
• Respiratory rate 10/min: A respiratory rate under 12 breaths per minute following opioid administration is a major red flag for opioid-induced respiratory depression. Immediate action is needed to prevent further decline in respiratory status, including potential use of naloxone.
• Blood pressure 98/58 mm Hg: The client’s blood pressure has dropped significantly compared to the earlier reading, suggesting opioid-related hypotension. While not yet critically low, the trend combined with other overdose signs indicates instability needing close monitoring and intervention.
• Heart rate 58/min: Although the client is bradycardic, this alone is not the most urgent issue compared to respiratory depression and neurological decline. It should still be monitored closely, but it is less immediately life-threatening than the airway and breathing concerns.
• Temperature 37.4° C (99.4° F): This temperature is within normal range and does not require follow-up. There are no indications of infection or thermoregulatory issues based on the current temperature.

A. Changing a sterile dressing for a client who is postoperative: Changing a sterile dressing requires the use of sterile technique and nursing judgment, making it a task that must be performed by a licensed nurse, not delegated to assistive personnel.

B. Performing a gastrostomy feeding on a stable client: While assistive personnel can assist with feeding in general, administering a gastrostomy feeding requires specific assessment and verification of tube placement, which must be done by a licensed nurse.

C. Observing the patency of an intravenous catheter on a stable client: Observing and assessing IV catheter patency is a nursing responsibility. It requires assessment skills and cannot be delegated to assistive personnel.

D. Providing postmortem care to a client: Providing postmortem care, such as bathing, positioning, and preparing the body, is a task that can be safely delegated to assistive personnel, following proper facility protocols and respectful handling of the deceased.