NCLEX-RNPsychosocial IntegrityHard
Emergency responders bring in an unresponsive client with pinpoint pupils, a respiratory rate of 6 breaths/min, and shallow breathing. A friend states the client "took some pills" a short time ago. What is the nurse's priority action?
- AObtain a urine toxicology screen.
- BContact the client's family for medication history.
- CAdminister naloxone as prescribed and support ventilation.
- DPosition the client on their side and reassess in 15 minutes.
Show answer & explanationAnswer & explanation
Correct answer: C. Administer naloxone as prescribed and support ventilation.
Pinpoint pupils and severe respiratory depression are classic signs of opioid overdose, a life-threatening emergency requiring immediate reversal with naloxone and airway/ventilatory support; delaying for diagnostic tests or history-gathering could result in death from respiratory failure.
Why the other options are wrong
- A. Diagnostic testing does not address the immediate life-threatening respiratory depression.
- B. Gathering history is important but not before addressing the airway/breathing emergency.
- D. Waiting 15 minutes risks respiratory arrest and hypoxic injury or death.
Opioid Overdose Management
A medical emergency characterized by CNS/respiratory depression and pinpoint pupils requiring immediate naloxone administration and airway support.
- Classic triad: pinpoint pupils, respiratory depression, decreased LOC
- Naloxone (Narcan) reverses opioid effects rapidly
- Airway/breathing (ABCs) take priority over diagnostics
- May need repeat naloxone dosing due to short half-life
Memory trick: Pinpoint pupils + slow breath = Narcan now, not later.