A nurse is assisting with the care of a client who last used heroin 8 hr ago. Which of the following findings should the nurse identify as a manifestation of opioid withdrawal?

A. Clamp the urinary catheter tubing: Clamping the catheter tubing is not appropriate because it can lead to bladder distention, increased pressure, and risk of bladder rupture. Maintaining continuous drainage is essential to prevent complications following prostate surgery.

B. Replace the indwelling urinary catheter with a smaller diameter catheter: Replacing the catheter is not the first intervention when clots and dark red blood are present. Smaller diameter catheters would actually be less effective in clearing clots and could worsen the blockage.

C. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation: Manual irrigation helps to clear clots that may be obstructing the catheter, promoting continued drainage and reducing the risk of bladder distention. Gentle irrigation is the appropriate first step to manage clot formation.

D. Allow the tubing to hang below the drainage bag: The drainage tubing should always be positioned above the collection bag to maintain gravitational drainage. Letting the tubing hang below the bag would impair drainage and could lead to backflow and infection.

• 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.