When administering zolpidem to an older client, which computer documentation indicates that the desired outcome has been achieved?

Choice A reason:

Taking an initial respiratory rate is a necessary action to ensure safety during morphine administration, as morphine can cause respiratory depression, which is a potentially life-threatening side effect. The nurse should monitor the client's respiratory rate and oxygen saturation regularly and report any signs of respiratory distress or hypoxia to the physician. Therefore, choice A is correct.

Choice B reason:

Performing a 12-lead electrocardiogram is not a necessary action to ensure safety during morphine administration, as morphine does not have a significant effect on the cardiac rhythm or conduction. The nurse should monitor the client's heart rate and blood pressure regularly and report any signs of bradycardia, hypotension, or chest pain to the physician. Therefore, choice B is incorrect.

Choice C reason:

Suctioning the client to clear the airway is not a necessary action to ensure safety during morphine administration, as morphine does not cause excessive secretions or bronchospasm that would obstruct the airway. The nurse should assess the client's level of consciousness and gag reflex regularly and report any signs of sedation, confusion, or aspiration to the physician. Therefore, choice C is incorrect.

Choice D reason:

Having a manual resuscitation bag at the bedside is a necessary action to ensure safety during morphine administration, as morphine can cause respiratory depression that may require emergency intervention. The nurse should be prepared to administer oxygen and naloxone (an opioid antagonist) as ordered and perform rescue breathing or cardiopulmonary resuscitation if needed. Therefore, choice D is correct.

Choice E reason:

Asking the client about other medications she takes is a necessary action to ensure safety during morphine administration, as morphine can interact with other drugs that may enhance or reduce its effects or cause adverse reactions. The nurse should review the client's medication history and current medications and report any potential drug interactions or contraindications to the physician. Therefore, choice E is correct.

Choice F reason:

Restraining the client with soft restraints is not a necessary action to ensure safety during morphine administration, as morphine does not cause agitation or delirium that would warrant physical restraint. The nurse should provide a safe and comfortable environment for the client and report any signs of anxiety, hallucinations, or psychosis to the physician. Therefore, choice F is incorrect.

Choice A: Printing an electrocardiogram strip is not a priority in this situation. The client is not responsive and has a low respiratory rate, which indicates a possible overdose of morphine. The nurse should focus on reversing the effects of the opioid and maintaining the client's airway and circulation.

Choice B: Providing rescue breaths with a manual ventilation bag is a correct and urgent action. It can supply oxygen to the client until naloxone takes effect and restore normal breathing.

Choice C: Giving naloxone 2 mg intravenously is a correct and urgent action. Naloxone is an opioid antagonist that can block the effects of morphine and reverse respiratory depression.

Choice D: This can help increase the patient’s oxygen levels, which may be low due to the decreased respiratory rate.

Choice E: Performing chest compressions is not a correct or urgent action. It is only indicated if the client has no pulse or signs of life. It can also cause harm if the client has a heartbeat.

Choice F: Calling for rapid response is a correct and urgent action. Rapid response is a team of health care professionals that can assist in emergency situations and provide advanced care.