hard · NCLEX-RN Reduction of Risk Potential
A nurse is caring for a 62-year-old client who received IV fentanyl for moderate procedural sedation during a painful debridement procedure. The client experienced respiratory depression (respiratory rate of 6/min and EtCO2 of 55 mm Hg) and was successfully reversed with IV naloxone. Which of the following interventions must the nurse perform? Select all that apply.
- Keep a replacement dose of naloxone immediately available at the client's bedside.
- Initiate a high-rate continuous infusion of naloxone immediately to ensure the client does not fall back asleep.
- Inform the family that the client is fully cured of opioid oversedation and can be safely discharged home.
- Assess the client's pain level and monitor for signs of acute return of severe pain or autonomic instability, such as severe hypertension and tachycardia.
- Maintain continuous capnography and pulse oximetry monitoring for at least 2 hours following naloxone administration.
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