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.
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Related Questions
Correct Answer is D
Explanation
A. Fever is not a common side effect of allopurinol.
B. Allopurinol is usually taken with food to minimize gastrointestinal upset.
C. If a rash develops, the client should stop taking allopurinol and notify their healthcare provider rather than self-medicating with an antihistamine.
D. Drinking an adequate amount of water helps prevent kidney stones, a potential side effect of allopurinol.
Correct Answer is B
Explanation
A. Antihistamines typically cause a mild decrease in blood pressure.
B. Antihistamines often have anticholinergic effects, leading to dry mouth.
C. This is not a common adverse effect of antihistamines.
D. Antihistamines are more likely to cause constipation than diarrhea.
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