Patient Data Which should the nurse do immediately? Select all that apply.

A. Print an electrocardiogram strip: While cardiac monitoring is important, printing an ECG strip does not immediately address the critical issue of respiratory depression and unresponsiveness. Priority actions must focus on airway and breathing first. B. Call for rapid response: The client is critically unstable with severe respiratory depression and unresponsiveness, meeting criteria for a rapid response or even a code blue if the situation deteriorates further. Immediate expert team support is crucial. C. Perform chest compressions: Chest compressions are only indicated if the client is pulseless. In this case, the client has a heart rate of 92 beats/minute, meaning compressions are not appropriate at this moment. D. Apply oxygen via nasal cannula: A nasal cannula would not deliver high enough oxygen concentrations for someone with a respiratory rate of 5 breaths/minute and oxygen saturation of 54%. Higher oxygen delivery methods and ventilatory support are urgently needed. E. Give naloxone 2 mg intravenous push: Naloxone is indicated immediately to reverse opioid-induced respiratory depression. Giving the prescribed naloxone IV push can rapidly counteract the morphine overdose and improve the client’s respiratory effort. F. Provide rescue breaths with a manual ventilation bag: Because the client’s respirations are critically low, rescue breathing with a manual resuscitation bag is necessary to maintain oxygenation and ventilation until naloxone takes effect or more advanced airway management is available.