hard · NCLEX-RN risk-reduction

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.

1. Keep a replacement dose of naloxone immediately available at the client's bedside.
2. Initiate a high-rate continuous infusion of naloxone immediately to ensure the client does not fall back asleep.
3. Inform the family that the client is fully cured of opioid oversedation and can be safely discharged home.
4. 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.
5. Maintain continuous capnography and pulse oximetry monitoring for at least 2 hours following naloxone administration.

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