The patient receiving a continuous hydromorphone infusion for severe cancer pain is found to be unconscious with a respiratory rate of 7 breaths per minute. Which action does the nurse take first?

Incorrect

  • Call the rapid response team
  • Gently attempt to wake the patient 
  • Administer naloxone PRN as ordered
  • Determine oxygen saturation by pulse oximetry

Rationale

The patient is exhibiting opioid-induced respiratory depression, but it has not been determined if the patient is unable to be aroused. First, the nurse attempts to wake the patient gently. If the patient does not arouse, the nurse contacts the provider. It is helpful to determine the patient’s oxygen saturation by pulse oximetry, but 7 breaths per minute is too low and must be acted upon. After the nurse contacts the provider, naloxone may be administered per the provider. The rapid response team may be needed, but it is not the initial action.

  • Category: Pharmacological and Parenteral Therapies
  • Difficulty: 8
  • Tags: Cardiovascular Delegation, Prioritization and Leadership Neurology Respiratory

Question 73 of 75

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