An LPN is assisting a 52-year-old woman on a rehabilitation unit who is recovering from a traumatic brain injury and receiving scheduled oral opioid analgesia for post-surgical spinal pain. Thirty minutes after her morning dose, the nurse enters the room to reposition her and finds her unresponsive in bed. Her call light was not activated. The nurse taps her shoulder and shouts her name with no response. Baseline vital signs one hour earlier were BP 118/72, HR 78, RR 16, SpO2 97% on room air, temperature 98.4°F, and she was alert and oriented to person, place, and time. What should the nurse do first?
- Obtain and chart a complete set of vital signs before calling for emergency assistance.
- Activate emergency assistance, rapidly assess breathing and pulse together, and begin indicated basic life support.
- Complete an incident report about the opioid dose before beginning rescue measures.
- Diagnose opioid overdose and independently select a reversal-drug regimen before checking breathing or circulation.