Which of the following additional assessment data should immediately be gathered to determine the status of a client with a respiratory rate of 4 breaths/minute?
A. Arterial blood gas (ABG) and breath sounds.
B. Level of consciousness and a pulse oximetry value.
C. Breath sounds and reflexes.
D. Pulse oximetry value and heart sounds.
Correct Answer: B. Level of consciousness and a pulse oximetry value.
First, the nurse should attempt to rouse the client because this should increase the client’s respiratory rate. If available, a spot pulse oximetry check should be done and breath sounds should be checked. The physician should be notified immediately of the findings. The care of the patient at the scene depends on the vital signs. If the patient is comatose and in respiratory distress, airway control must be obtained before doing anything else.
Option A: He’ll probably order ABG analysis to determine specific carbon dioxide and oxygen levels, which will indicate the effectiveness of ventilation. If the physician suspects that the individual has overdosed on an opiate and has signs of respiratory and CNS depression, no time should be wasted on laboratory studies; instead, naloxone should be administered as soon as possible.
Option C: Reflexes and heart sounds will be part of the more extensive examination done after these initial actions are completed. An ECG is recommended in all patients with suspected opioid overdose. Coingestants like tricyclics have the potential to cause arrhythmias.
Option D: When a patient presents to the emergency department with any type of drug overdose, the ABCDE protocol has to be followed. In some cases, airway control has been obtained by emergency medical personnel at the scene, but if there is any sign of respiratory distress or failure to protect the airways in an un-intubated patient with a morphine overdose, one should not hesitate to intubate. In most emergency rooms, patients who present with an unknown cause of lethargy or loss of consciousness have their blood glucose levels drawn.
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