After being treated in the emergency department for an opioid overdose two weeks ago, a client arrives to an outpatient treatment clinic. During the admission interview with the nurse, the client denies having a problem with opioid addiction, but admits to gradually increasing the dosage. Which approach is best for the nurse to make?

Rationale:

• Respirations: After administering morphine, it is crucial to monitor the client's respirations because opioids can cause respiratory depression, which may be more pronounced in elderly patients or those who are in pain and immobile.
• Deep breathing techniques: The nurse should encourage deep breathing techniques. This helps improve lung expansion and reduces the risk of respiratory complications such as pneumonia and atelectasis, especially in a client with decreased mobility due to pain and injury.

Rationale for Incorrect Options:

• Heart rate: While heart rate monitoring is important, it is not the primary concern immediately after morphine administration. The client's respiratory status takes precedence, especially considering the risk of opioid-induced respiratory depression.
• Blood pressure: While blood pressure monitoring is essential, morphine administration primarily affects the respiratory system, not the circulatory system. The nurse should prioritize respiratory monitoring over blood pressure unless the patient exhibits signs of hypotension.
• Range of motion exercises: Range of motion exercises are important for mobility and rehabilitation, but they are not a priority immediately following the trauma and morphine administration. The client should be assessed and stabilized before beginning exercises.
• Joint protection techniques: Joint protection techniques are beneficial in long-term rehabilitation, but in the acute phase, the priority is to manage the fracture, pain, and prevent further complications.

A. While the presence of greenish fluid in a nasogastric tube can indicate a small bowel obstruction, this finding alone does not necessarily indicate an immediate life-threatening condition. The client should be monitored, but this is not the priority.

B. Abdominal rigidity in the context of a volvulus (twisting of the bowel) can indicate bowel ischemia or perforation, which is a surgical emergency. Immediate intervention is needed to prevent further complications such as sepsis or peritonitis.

C. A paralytic ileus is a common postoperative complication and often resolves with time. While the absence of bowel sounds is concerning, it is a routine finding in this situation and does not require immediate attention unless there are signs of further complications.

D. Abdominal distention in a large bowel obstruction can indicate a need for further assessment and treatment. However, compared to a volvulus with abdominal rigidity, this situation is less urgent and does not represent an immediate life-threatening emergency.