A nurse is monitoring a client who is receiving a vesicant for chemotherapy via an IV infusion and notices the client has developed extravasation. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Hydromorphone is a potent opioid analgesicthat provides relief through the stimulation of mu-opioid receptorsin the central nervous system. A dangerous side effect is respiratory depression, where the drug decreases the responsiveness of brainstem respiratory centers to carbon dioxide levels.

Rationale:

A.Prednisone is a corticosteroid used for its anti-inflammatory and immunosuppressive properties. It has no pharmacological ability to reverse the central nervous system depression caused by opioid agonists like hydromorphone. Administering prednisone to a client with a depressed respiratory rate would provide no benefit in managing the immediate risk of respiratory failure or apnea.

B.Naloxone is an opioid antagonist that competitively binds to mu-opioid receptors, rapidly displacing opioid molecules like hydromorphone. It is the gold standard for reversing opioid-induced respiratory depression, restoring a normal breathing rate and level of consciousness within minutes. The nurse must monitor the client closely after administration, as the half-life of naloxone is shorter than hydromorphone.

C.Epinephrine is a catecholamine used in the treatment of anaphylaxis, cardiac arrest, and severe hypotension. While it can stimulate the cardiovascular system, it is not a reversal agent for opioid toxicity. Using epinephrine for a depressed respiratory rate would not address the underlying receptor-level blockade causing the decreased ventilation and could cause unnecessary cardiac strain.

D.Flumazenil is a benzodiazepine antagonist used specifically to reverse the effects of drugs like diazepam or midazolam. It does not bind to opioid receptors and therefore cannot reverse the respiratory depression caused by hydromorphone. The nurse must correctly identify the offending drug class to ensure the proper antagonist is selected for emergency intervention.

Citalopram is a selective serotonin reuptake inhibitor(SSRI) used to manage major depressive disorder by increasing serotonin levelsin the synaptic cleft. While generally well-tolerated, SSRIs can cause serotonin syndrome, a potentially fatal condition characterized by altered mental status, autonomic instability, and neuromuscular hyperactivity. Early detection of neurological changes is vital.

Rationale:

A.Bruxism, or involuntary teeth grinding, is a known side effect of SSRIs that typically occurs during sleep. While it can cause dental wear and jaw pain, it is not a life-threatening emergency requiring immediate reporting. The nurse can suggest a mouth guard or a dosage adjustment during a routine follow-up with the provider to manage this specific discomfort.

B.Insomnia is a frequent side effect of citalopram due to the stimulating effects of increased serotonin in certain brain pathways. While significant for the client's quality of life, it is an expected reaction that often subsides after several weeks of therapy. It does not carry the same degree of clinical urgency as symptoms indicating acute toxicity or systemic physiological distress.

C.Weight loss can occur during the initial phase of citalopram therapy due to decreased appetite or nausea. While the nurse should monitor the client's nutritional intake and weight over time, it is a gradual process rather than an acute crisis. It is considered a manageable side effect that rarely requires immediate medical intervention unless the weight loss becomes extreme.

D.Confusion is a priority finding because it may indicate the onset of serotonin syndromeor significant hyponatremia, which are serious complications of SSRI therapy. Altered mental status is a "red flag" symptom that suggests systemic toxicity rather than a benign side effect. The nurse must report confusion immediately to ensure the client is evaluated for potentially life-threatening drug reactions.