A nurse is caring for a patient on a PCA hydromorphone pump who becomes unresponsive with shallow respirations. What action is the priority?

• A. Give naloxone intravenously per protocol.
• B. Assess the client's pain level on a 10-point scale.
• C. Document the vital signs in the client record.
• D. Notify the hospital rapid response team.

Answer: (A)

Immediate reversal of opioid-induced respiratory depression is the priority. When a patient on a PCA hydromorphone pump is unresponsive with shallow respirations, the most critical action is to give intravenous naloxone per protocol to compete at opioid receptors and rapidly restore breathing and consciousness. After naloxone is given, continue to monitor airway, breathing, circulation, and level of consciousness, and be prepared to repeat the dose or provide additional support as needed. While documenting vitals or notifying the rapid response team and reassessing pain are important, they are secondary to stopping the life-threatening respiratory depression first.