Advanced Medical-Surgical CJE Practice Exam 2026 - Free Medical-Surgical Practice Questions and Study Guide

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A client presents with respiratory depression, low blood pressure, and unresponsive to voice. What is the nurse's immediate priority action?

Administer intravenous naloxone

The immediate priority action in this scenario is to administer intravenous naloxone. The client's symptoms of respiratory depression and unresponsiveness are highly indicative of an opioid overdose, which naloxone is specifically designed to reverse. Naloxone is an opioid antagonist that works quickly to restore normal respiratory function and consciousness if opioids are the cause of the symptoms.

In cases of respiratory depression, particularly if opiate-related, addressing airway obstruction and ensuring adequate oxygenation are essential. However, the administration of naloxone is critical because it directly targets the underlying cause of the respiratory depression. While initiating oxygen therapy may be necessary later to support the client, and calling for emergency assistance is important, these actions do not tackle the acute issue as effectively or as quickly as administering naloxone.

Additionally, performing chest compressions would typically only be warranted if the client were pulseless, which is not indicated here based on the provided symptoms. Thus, the most immediate and effective response to the clinical presentation is the administration of intravenous naloxone.

Perform chest compressions

Start oxygen therapy

Call for emergency assistance

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