A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?

Rationale:

A. "You can lift objects that weigh 15 pounds.": Clients recovering from retinal detachment repair should avoid lifting heavy objects, even as light as 15 pounds. Increased intraocular pressure from straining can compromise the surgical repair.

B. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure and should be avoided postoperatively. Clients are advised to bend at the knees and keep their head upright to reduce pressure on the eye.

C. "Avoid reading for 3 days following surgery.": Reading is usually restricted only if it causes eye strain or requires eye movement that could interfere with healing. It is not routinely restricted for a set number of days unless otherwise specified by the surgeon.

D. "Take a stool softener daily.": Straining during bowel movements increases intra-abdominal and intraocular pressure. Stool softeners help prevent straining, making them a useful part of postoperative care after eye surgery to protect the surgical site.

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.