The nurse observes that a client has become lethargic 30 minutes after receiving an opioid injection for pain. Which vital sign should the nurse obtain first?

A. Initiate cardiopulmonary resuscitation (CPR):
While initiating CPR is critical for clients experiencing cardiac or respiratory arrest, it is not the immediate action in this scenario. The client’s respiratory depression is most likely related to opioid toxicity, which can sometimes be reversed with naloxone. Before resorting to CPR, the priority is to address the potential cause of the respiratory depression.
B. Prepare to assist with chest tube insertion:
Chest tube insertion is typically indicated for conditions such as pneumothorax or pleural effusion, not for opioid-induced respiratory depression. In this case, the client’s symptoms are likely related to the effects of opioids and naloxone administration, not a need for chest tube insertion
C. Determine Glasgow Coma Scale score:
While assessing the Glasgow Coma Scale (GCS) score is important for evaluating the client's level of consciousness and neurological status, it does not address the immediate need to counteract opioid toxicity. The priority is to manage the respiratory depression that could be life-threatening.
D. Administer a second dose of naloxone:
Administering a second dose of naloxone is the most appropriate action in this scenario. Naloxone is used to reverse opioid-induced respiratory depression, and if the initial dose did not fully counteract the effects of the opioid, a second dose may be necessary. The client's severe respiratory depression and low oxygen saturation indicate that opioid effects may still be present, warranting additional naloxone administration.

A. Serum ammonia level of 30 μg/dl (17.62 μmol/dL):
Sodium polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. It does not affect serum ammonia levels, which are more relevant in cases of liver dysfunction or urea cycle disorders. Thus, this finding does not indicate the effectiveness of the medication.
B. Hemoglobin level of 13.5 g/dL (135 g/L):
Hemoglobin levels are related to anemia or blood disorders and are not directly affected by sodium polystyrene sulfonate. This lab result would not indicate the effectiveness of the medication in managing potassium levels.
C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L):
Sodium polystyrene sulfonate is specifically used to lower elevated potassium levels. A serum potassium level within the normal range (3.5 to 5 mEq/L) indicates that the medication has been effective in reducing hyperkalemia, which is the primary goal of treatment with this drug.
D. Serum glucose level of 120 mg/dL (6.7 mmol/L):
While glucose levels are important for overall metabolic management, they are not directly impacted by sodium polystyrene sulfonate. This result would not reflect the effectiveness of the medication in treating elevated potassium levels in acute kidney injury.