Exhibits

A nurse is collecting data from a client who has pneumonia and a prescription for cefazolin. Which of the following findings should the nurse report to the provider prior to administering the initial dose? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale for correct choices

• naloxone: The client demonstrates signs of opioid-induced respiratory depression, including a respiratory rate of 10/min, hypotension, and declining oxygen saturation despite supplemental oxygen. Fentanyl was administered shortly before the deterioration, making opioid reversal a priority. Naloxone rapidly reverses opioid effects and can improve respiratory drive and blood pressure.

• oxygen 10 L/min via face mask: The client’s oxygen saturation has dropped to 87% on 2 L/min via nasal cannula, indicating inadequate oxygenation. Escalating oxygen delivery with a face mask provides a higher concentration of oxygen to support ventilation while reversal agents take effect. This intervention addresses acute hypoxemia and reduces the risk of respiratory failure.

Rationale for incorrect choices

• an additional dose of fentanyl: Fentanyl is a potent opioid that can further suppress respiratory drive and worsen hypotension. The client is already showing adverse effects consistent with opioid overdose. Administering additional fentanyl would increase the risk of apnea and cardiovascular collapse.

• propranolol: Propranolol is a beta-blocker used to manage hypertension, tachycardia, or certain cardiac conditions. The client is hypotensive and bradycardic, making beta-blockade unsafe. This medication would further decrease heart rate and blood pressure.

• acetaminophen: Acetaminophen may help manage pain but does not address the client’s acute respiratory depression or hypoxia. The priority is airway and breathing stabilization rather than pain control. Delaying corrective interventions could result in rapid clinical deterioration.

• an additional dose of propofol: Propofol is a sedative-hypnotic that can cause significant respiratory depression and hypotension. The client is already experiencing these adverse effects following sedation. Additional propofol would worsen oxygenation and cardiovascular instability.

A. Avoid attempting to distract the client away from the hallucination: While it is important not to reinforce hallucinations, gentle redirection or distraction can help the client focus on reality and reduce distress. Avoiding all attempts at distraction may increase anxiety or withdrawal.

B. Encourage group activities: Clients actively experiencing hallucinations may have difficulty concentrating or interacting safely in a group setting. Encouraging participation at this time could increase agitation or confusion. Individualized, low-stimulation interventions are preferable.

C. Provide low lighting in the client's room: Low, soft lighting reduces environmental stimuli that can exacerbate hallucinations or agitation. Creating a calm, quiet environment supports reality orientation and helps the client manage sensory overload.

D. Use touch to convey acceptance: Physical touch may startle, confuse, or distress a client experiencing hallucinations. Safety and personal boundaries should be maintained, and touch should generally be avoided unless the client initiates or clearly consents.