A nurse is reviewing data for a client who receives clonidine daily.
Which of the following findings indicates the nurse should withhold the next dose?

Choice A rationale:

Oxycodone overdose typically results in constricted (not dilated) pupils due to its action on the central nervous system.

Choice B rationale:

Oxycodone overdose can cause respiratory depression, leading to slow and shallow breathing (bradypnea), not rapid breathing (tachypnea)

Choice C rationale:

Oxycodone does not typically cause tachycardia. It can cause bradycardia due to its action on the central nervous system.

Choice D rationale:

Sedation is a common effect of oxycodone and can be more pronounced in cases of overdose due to the drug’s depressant effect on the central nervous system.

Choice A rationale:

Hanging the antibiotic medication bag above the level of the primary infusion is an important step in administering an antibiotic via intermittent IV bolus. However, it is not the first step. The medication bag is usually hung higher to allow the antibiotic to infuse by gravity once it’s connected.

Choice B rationale:

Wiping the connection port of the primary IV tubing with an antiseptic swab is a crucial step in preventing infection. However, this is typically done just before connecting the secondary line, not as the first step.

Choice C rationale:

Checking the IV site for signs of infiltration is indeed the first step. It’s important to ensure that the IV catheter is still properly placed in the vein and that there are no signs of infection or infiltration, which could cause complications.

Choice D rationale:

Connecting the tubing of the medication bag to the primary tubing is done after cleaning the port and before hanging the bag. It’s not the first step.