A nurse reviews the results of three fecal occult blood tests (FOBT) with a client. The tests returned positive. What action should the nurse plan to take?

Rationale:
A. Respiratory rate is the most important assessment before administering a medication that can cause respiratory depression, such as opioids or certain sedatives. These medications act on the central nervous system to reduce the drive to breathe, which can result in hypoventilation, decreased oxygenation, and, in severe cases, respiratory arrest. By assessing the client’s baseline respiratory rate, depth, and effort, the nurse can determine whether it is safe to administer the medication and establish a reference point for monitoring after administration. Identifying a low or irregular respiratory rate before giving the medication allows the nurse to intervene promptly, adjust the dose, or withhold the medication if necessary, ensuring patient safety.

B. Blood pressure is an important vital sign to monitor with many medications, as hypotension can be a side effect, especially with opioids. However, while low blood pressure may indicate hemodynamic instability, it is not the immediate risk associated with respiratory-depressant medications. Monitoring blood pressure is secondary to assessing respiratory function in this scenario.

C. Apical pulse rate is important for medications that affect cardiac function, such as antiarrhythmics or beta-blockers. While a slow or irregular heart rate can be concerning, it does not directly indicate the risk of respiratory depression, which is the primary safety concern with this type of pain medication.

D. Pain level assessment is necessary to determine the need for medication and to evaluate its effectiveness. However, assessing pain alone does not ensure safe administration. If a client is at risk for respiratory depression, giving medication without checking respiratory status could result in life-threatening complications.

Rationale:
A. The statement that medication is delivered more quickly with a spacer is incorrect. A spacer does not speed up delivery; rather, it improves the efficiency of inhalation by allowing the medication to be inhaled slowly and deeply.

B. A spacer is not required for every person using a metered-dose inhaler (MDI). While beneficial, some clients can use an MDI effectively without a spacer if proper technique is mastered.

C. Using a spacer does not eliminate the need to wait between puffs. Proper timing between puffs is still necessary to allow the medication to work effectively in the lungs.

D. The correct response is that the spacer allows the client to inhale the medication more slowly and deeply. This improves delivery of the medication to the lower airways, reduces deposition in the mouth and throat, enhances therapeutic effectiveness, and can decrease local side effects such as irritation or oral candidiasis.