A nurse is caring for a client who has AIDS. The client states, "My mouth is sore when I eat." Which of the following instructions should the nurse provide?

Rationale for correct choices:

• Opioid intoxication: The client shows hallmark signs of opioid overdose, including respiratory depression, bradycardia, hypotension, miosis (pupillary constriction), confusion, and hypothermia. A history of oxycodone use and psychosocial stressors support opioid misuse.
• Obtain prescription for naloxone: Naloxone is a competitive opioid antagonist that rapidly reverses the life-threatening effects of opioid toxicity, particularly respiratory depression and central nervous system suppression.
• Prepare to initiate mechanical ventilation: The client’s respiratory rate is critically low at 10 breaths/min with oxygen saturation at 90%. Mechanical ventilation may be necessary if the client cannot maintain adequate oxygenation even after naloxone administration.
• Respiratory rate: This is a key indicator of opioid intoxication severity and response to naloxone. Ongoing monitoring is essential to assess ventilation adequacy and detect recurrent respiratory depression.
• Pupillary reaction: Miosis is a key sign of opioid overdose, and pupil size can help gauge the severity of intoxication. As naloxone takes effect, pupils typically dilate, signaling reversal.

Rationale for incorrect choices:

• Alcohol intoxication: While the client has a history of alcohol use disorder, the physical findings (e.g., pinpoint pupils, bradycardia, low respiratory rate) are more consistent with opioid toxicity than ethanol intoxication.
• Stimulant intoxication: Stimulant overdose would present with hypertension, hyperthermia, tachycardia, and dilated pupils not the bradycardia, hypothermia, and miosis seen here.
• Opioid withdrawal: Opioid withdrawal typically presents with symptoms like dilated pupils, tachycardia, agitation, and diaphoresis—not CNS depression and hypoventilation.
• Obtain prescription for restraints: There is no evidence of violent or aggressive behavior requiring restraints; the client is sedated and obtunded, not agitated or combative.
• Collect a blood sample for ethanol level: This might be helpful later, but it does not take priority in a client presenting with acute signs of opioid overdose. Immediate interventions to support breathing are more urgent.
• Cardiac arrhythmias: Although bradycardia is present, continuous ECG monitoring may be useful, but arrhythmias are not the primary risk in opioid overdose compared to respiratory depression.
• Ethanol level: Alcohol toxicity is not the most likely cause here, so monitoring ethanol level will not help guide the immediate treatment and stabilization of this client.

Rationale:

A. Raise the head of the bed when transferring a client from a bed to a stretcher: Raising the head of the bed alters body mechanics and may complicate the transfer by increasing the angle of elevation, which can lead to strain or improper alignment during the move.

B. Use a pillow underneath the client's head when repositioning a client in bed: A pillow can aid in comfort but does not contribute to safe body mechanics during repositioning. It may also interfere with alignment or reduce the ability to properly lift or turn the client.

C. Transfer on the client's weaker side when moving a client from a bed to a chair: Transferring toward the weaker side increases the risk of instability and falls. Safe ergonomic practice involves moving clients toward their stronger side to encourage participation and minimize staff effort.

D. Use a lateral transfer device when moving a client from a bed to a stretcher: Lateral transfer devices reduce friction between surfaces, making it easier to move the client without excessive force. This protects both the client and the nurse from musculoskeletal injuries and supports safe practice.