A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

Rationale for correct choices:

• Opioid intoxication: The client exhibits classic signs of opioid overdose, including shallow respirations, bradypnea, bradycardia, hypotension, hypothermia, slurred speech, and constricted pupils. These findings, combined with a history of oxycodone use, indicate opioid intoxication requiring immediate intervention.
• Obtain a prescription for naloxone: Naloxone is an opioid antagonist that reverses the respiratory depression, sedation, and other life-threatening effects of opioid overdose. Timely administration can prevent respiratory failure and death.
• Prepare to initiate mechanical ventilation: The client’s respiratory rate is critically low (10/min) with oxygen saturation at 90%, indicating inadequate ventilation. Mechanical ventilation may be required to maintain oxygenation and prevent hypoxia while naloxone takes effect.
• Pupillary reaction: Monitoring pupillary constriction or dilation helps assess the client’s response to opioid reversal therapy and can indicate ongoing central nervous system depression or improvement.
• Respiratory rate: Continuous monitoring of respiratory rate is essential because hypoventilation is the most immediate life-threatening effect of opioid intoxication. Changes indicate whether interventions like naloxone or ventilation are effective.

Rationale for incorrect choices:

• Alcohol intoxication: Although the client has a history of alcohol use disorder, the current symptoms of miosis, hypoventilation, and hypotension are more consistent with opioid toxicity rather than acute alcohol intoxication.
• Opioid withdrawal: Withdrawal presents with agitation, tachypnea, hypertension, dilated pupils, diaphoresis, and GI upset. This client’s bradycardia, hypotension, and hypoventilation indicate intoxication, not withdrawal.
• Stimulant intoxication: Stimulant overdose typically presents with hypertension, tachycardia, hyperthermia, and agitation. The client’s hypotension, bradycardia, and CNS depression are inconsistent with stimulant use.
• Anticipate administering clonidine: Clonidine is used for opioid withdrawal management, not acute intoxication. Administering it in this scenario would not address the life-threatening hypoventilation or CNS depression.
• Collect a blood sample for ethanol level: While it may be helpful for history, ethanol testing does not address the immediate life-threatening opioid overdose and is not a priority intervention.
• Obtain prescription for restraints: There is no indication for restraints. The client’s symptoms are due to CNS depression, and restraints would not improve their condition and could worsen injury risk.
• Hyperreflexia: This is a sign of opioid withdrawal or CNS stimulant activity, not opioid intoxication. The client’s deep tendon reflexes are decreased, consistent with CNS depression.
• Cardiac arrhythmias: While arrhythmias can occur, there is no evidence in this assessment of dysrhythmias. Monitoring vital signs and oxygenation is more immediately critical.

Rationale:

• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: The nurse should follow the ordered transfusion rate and not titrate it based on blood pressure. The priority is to transfuse the blood safely and at the prescribed rate, while monitoring the client's response. Blood pressure will improve as the blood volume is restored.
• Obtain the first unit of packed RBCs from the blood bank: This is necessary to correct the client’s anemia (Hgb 9.1 g/dL, Hct 27%) and address the suspected acute blood loss indicated by positive hemoccult stool and hemodynamic changes.
• Document the blood product transfusion in the client's medical record: Accurate documentation ensures legal compliance, tracks the administration, and records the client’s response, including any adverse events, supporting continuity of care.
• Stay with the client for the first 15 min of the transfusion: Most transfusion reactions occur during the first 15 minutes. Close observation allows for immediate intervention if the client develops fever, hypotension, or other adverse effects.

• Start an IV bolus of lactated Ringer's solution: Lactated Ringer’s contains calcium which can cause clotting in the transfusion line. Using LR can lead to hemolysis or transfusion complications. Only 0.9% sodium chloride should be used for flushing or running alongside blood transfusions.