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NCLEX Question of the Day
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A nurse is monitoring a client receiving an epidural infusion of fentanyl for postoperative pain. The client's respiratory rate is 8 breaths/min, and the client is difficult to arouse. What is the nurse's priority action?
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Assess the client's pain level.
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Administer oxygen via nasal cannula.
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Stop the epidural infusion.
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Correct answer Attempt to arouse the client and administer naloxone if prescribed.
Rationale
The client is exhibiting signs of significant respiratory depression (RR 8/min, difficult to arouse), a serious adverse effect of epidural opioids like fentanyl. The priority is to reverse the opioid effect while ensuring adequate ventilation. Attempting to arouse the client (verbal and physical stimuli) can sometimes improve respiratory effort. If unsuccessful or if respiratory depression is severe, administering an opioid antagonist like naloxone (if available via standing order or after contacting the provider) is the definitive action to reverse respiratory depression. Stopping the infusion is necessary but doesn't reverse the existing effect. Administering oxygen is supportive but doesn't correct the underlying cause (opioid-induced hypoventilation). Assessing pain is not the priority when respiratory depression is present.
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