A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?
Elevate the head of the bed to a 45 degree angle.
Lift and lock the side rails in place.
Apply the client's positive airway pressure device.
Remove dentures or other oral appliance.
The Correct Answer is C
A. Elevate the head of the bed to a 45-degree angle:
Elevating the head of the bed can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. While this intervention is important, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.
B. Lift and lock the side rails in place:
Ensuring the safety of the client by lifting and locking the side rails is important, but it does not directly address the client's OSA or the potential respiratory depression associated with opioid analgesic administration.
C. Apply the client's positive airway pressure device:
This is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.
D. Remove dentures or other oral appliance:
While removing dentures or other oral appliances may be necessary for client comfort and safety, it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Provide a numeric pain scale:
While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.
B. Observe body language and movement:
Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.
C. Ask the client to describe the pain:
This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.
D. Identify effective pain relief measures:
Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.
Correct Answer is ["0.5"]
Explanation
To find out how many milliliters the nurse should administer, we first need to calculate the volume required to deliver 200 mg of streptomycin.
Given:
Streptomycin concentration: 1 gram/2.5 mL
Dose prescribed: 200 mg
We'll start by converting the dose prescribed from milligrams (mg) to grams (g) since the concentration is given in grams:
200 mg = 0.2 grams
Now, we can set up a proportion to find the volume (x) needed to deliver 0.2 grams of streptomycin:
1 gram / 2.5 mL = 0.2 grams / x
Cross-multiplying:
1 * x = 0.2 * 2.5
x = 0.5 mL
So, the nurse should administer 0.5 milliliters of streptomycin.
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