On admission, the healthcare provider prescribes a broad spectrum antibiotic for a client with a gram-negative infection. Before administering the first dose, it is most important for the nurse to implement which prescription?

Choice B reason: Naloxone may be necessary, but first, the source of overdose (patches) must be removed to prevent further opioid absorption. After removal, the nurse should assess the severity and then administer naloxone if needed.

Choice A reason: Applying oxygen face mask is not the first action that the nurse should take in this situation, but rather a supportive measure that can be done after administering naloxone. Oxygen can help to improve the client's oxygenation and prevent hypoxia, but it will not reverse the opioid overdose.

Choice C reason: The client is exhibiting signs of opioid overdose, including respiratory depression (shortness of breath) and decreased level of consciousness (difficult to arouse). The first priority is to remove the excess morphine patches to stop further opioid absorption and prevent worsening of the overdose.

Choice D reason: Monitoring blood pressure is not the first action that the nurse should take in this situation, but rather an ongoing assessment that can be done after administering naloxone. Monitoring blood pressure can help to detect any changes in the client's hemodynamic status and guide further interventions, but it will not reverse the opioid overdose.

Choice A reason: Determining when the last dose was administered is important to ensure safe and effective pain management, but it is not the first action that the nurse should implement. The nurse should first assess the client's pain level and intensity before deciding on the appropriate dose and frequency of pain medication.

Choice B reason: Encouraging the client to use diversional thoughts to manage pain is a non-pharmacological intervention that can help reduce pain perception and anxiety, but it is not sufficient to address severe or acute pain. The nurse should first assess the client's pain level and intensity before suggesting any complementary or alternative therapies.

Choice C reason: Asking the client to rate the current level of pain using a pain scale is the first action that the nurse should implement, as it can help quantify and communicate the client's pain experience and guide the nurse's decision on pain medication. The nurse should use a valid and reliable pain scale that is appropriate for the client's age, cognitive ability, and language preference.

Choice D reason: Reviewing the history for a past use of recreational drugs is relevant to assess the client's risk of addiction or tolerance to pain medication, but it is not the first action that the nurse should implement. The nurse should first assess the client's pain level and intensity before considering any factors that may influence pain management.