A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?

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.

A. Document the client's level of understanding about potential adverse effects: Documentation is important but should occur after assessing the client’s knowledge and providing teaching.

B. Determine the client's knowledge about diaphragm use: Assessment is the first step in the nursing process. Understanding the client’s baseline knowledge allows the nurse to tailor teaching and identify misconceptions before providing instruction.

C. Supervise return demonstration of diaphragm use: Return demonstration evaluates learning but is only appropriate after teaching and assessment have been completed.

D. Teach the client how to insert the diaphragm: Teaching is essential but should follow assessment of the client’s current understanding to ensure the instruction is effective and appropriate.