A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP?

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. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.

B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.

C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.

D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.