A nurse is assessing a client who is taking clozapine. For which of the following adverse effects should the nurse monitor and report to the provider?

Rationale:

A. Palpate the client's bladder in 1 hour: Waiting another hour to assess the bladder delays intervention. At 10 hours postpartum with no void, immediate action is needed to stimulate voiding or assess for urinary retention.

B. Place the client's hands in a bowl of cold water: This technique is more commonly used in children and is less effective in stimulating voiding in postpartum adults. It is not a first-line strategy in this context.

C. Have the client listen to running water while on the toilet: This is a noninvasive and effective method to stimulate the urge to void by triggering the micturition reflex. It can help relax pelvic muscles and encourage urination postpartum.

D. Perform effleurage over the client's lower abdomen: Effleurage is a light massage technique used primarily for labor pain management. It is not a recognized or effective method to promote urination in postpartum care.

Rationale for correct choices:

• Opioid intoxication: The client shows hallmark signs of opioid overdose, including respiratory depression, bradycardia, hypotension, miosis (pupillary constriction), confusion, and hypothermia. A history of oxycodone use and psychosocial stressors support opioid misuse.
• Obtain prescription for naloxone: Naloxone is a competitive opioid antagonist that rapidly reverses the life-threatening effects of opioid toxicity, particularly respiratory depression and central nervous system suppression.
• Prepare to initiate mechanical ventilation: The client’s respiratory rate is critically low at 10 breaths/min with oxygen saturation at 90%. Mechanical ventilation may be necessary if the client cannot maintain adequate oxygenation even after naloxone administration.
• Respiratory rate: This is a key indicator of opioid intoxication severity and response to naloxone. Ongoing monitoring is essential to assess ventilation adequacy and detect recurrent respiratory depression.
• Pupillary reaction: Miosis is a key sign of opioid overdose, and pupil size can help gauge the severity of intoxication. As naloxone takes effect, pupils typically dilate, signaling reversal.

Rationale for incorrect choices:

• Alcohol intoxication: While the client has a history of alcohol use disorder, the physical findings (e.g., pinpoint pupils, bradycardia, low respiratory rate) are more consistent with opioid toxicity than ethanol intoxication.
• Stimulant intoxication: Stimulant overdose would present with hypertension, hyperthermia, tachycardia, and dilated pupils not the bradycardia, hypothermia, and miosis seen here.
• Opioid withdrawal: Opioid withdrawal typically presents with symptoms like dilated pupils, tachycardia, agitation, and diaphoresis—not CNS depression and hypoventilation.
• Obtain prescription for restraints: There is no evidence of violent or aggressive behavior requiring restraints; the client is sedated and obtunded, not agitated or combative.
• Collect a blood sample for ethanol level: This might be helpful later, but it does not take priority in a client presenting with acute signs of opioid overdose. Immediate interventions to support breathing are more urgent.
• Cardiac arrhythmias: Although bradycardia is present, continuous ECG monitoring may be useful, but arrhythmias are not the primary risk in opioid overdose compared to respiratory depression.
• Ethanol level: Alcohol toxicity is not the most likely cause here, so monitoring ethanol level will not help guide the immediate treatment and stabilization of this client.