A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)
Instruct the client on use of call light.
Apply an ambulation alarm to the client’s leg.
Apply restraints to the client PRN.
Raise the four side rails of the client’s bed.
Check on the client hourly
Correct Answer : A,B,D,E
A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.
C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.
E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acetaminophen is often the initial choice for managing osteoarthritis pain in older adults due to its lower risk of gastrointestinal and cardiovascular side effects.
B. Celecoxib and ibuprofen are NSAIDs that may be considered but are associated with a higher risk of side effects, especially in older adults.
C. Hyaluronic acid injections are typically considered if oral medications are not effective, and the patient has persistent symptoms.
D. Ibuprofen is an NSAID and is associated with increased risk of gastrointestinal bleeding and renal impairment hence is not considered as a first line management of osteoarthritis.
Correct Answer is B
Explanation
A. Saw palmetto is often used for prostate health, not for preventing UTIs.
B. Cranberry juice has been associated with a decreased risk of UTIs, particularly in women.
C. Black cohosh is primarily used for menopausal symptoms, not for preventing UTIs.
D. Echinacea is commonly used for immune system support but is not specifically known for preventing UTIs.
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