A nurse is caring for a client who is incontinent of bowel and bladder. Which of the following actions should the nurse take?

Choice A reason: Morphine-induced respiratory depression (RR 10, O2 Sat 85%) and hypotension (BP 88/42) indicate opioid overdose. Naloxone reverses opioid effects, while Fowler’s position and oxygen improve ventilation and oxygenation, addressing life-threatening symptoms as the priority.

Choice B reason: High Fowler’s position aids breathing but does not address morphine’s opioid effects causing respiratory depression and hypoxia. Alone, it is insufficient to reverse the underlying cause or stabilize the patient’s critical vital signs.

Choice C reason: Applying oxygen via nasal cannula improves oxygenation but does not reverse morphine’s central nervous system depression causing hypoventilation. It is a supportive measure, not the priority compared to naloxone administration.

Choice D reason: Flumazenil reverses benzodiazepines, not opioids like morphine. Administering it is inappropriate and ineffective for this scenario, and while oxygen is helpful, it is secondary to reversing the opioid overdose with naloxone.

Choice A reason: Scheduled toileting every 2 hours establishes a routine, compensating for dementia-related cognitive deficits in recognizing bladder cues. This promotes continence, reduces accidents, and maintains dignity, making it the most effective behavioral intervention.

Choice B reason: Indwelling catheters increase risks of urinary tract infections, skin breakdown, and discomfort, especially in dementia patients unable to communicate issues. They are a last resort, not appropriate for managing incontinence without medical necessity.

Choice C reason: Reminding a dementia patient to report urination needs is ineffective, as cognitive impairment limits their ability to recognize or communicate bladder signals. This approach does not address the underlying issue of incontinence.

Choice D reason: Adult diapers manage accidents but do not promote continence or address the behavior. They may reduce dignity and increase skin breakdown risk, making scheduled toileting a more proactive and dignified intervention.