Patient Data Exhibits What should the nurse do immediately? Select all that apply.
Explanation & Rationale
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.