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

Answer and Explanation

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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Correct Answer is D

Explanation

A. These symptoms are more commonly associated with gastrointestinal side effects of chemotherapy.
B. These symptoms are common due to the impact of chemotherapy on the gastrointestinal system.
C. Hair loss is a common side effect of chemotherapy, but it is not associated with myelosuppression.
D. Myelosuppression can lead to decreased platelet production, resulting in an increased risk of bleeding, including gum bleeding.

A. Instruct the client to stay in the bathtub no longer than 20 min. B. Fill the bathtub with water at 48 C (118.4° F). C. Use bath oil in the client’s bathtub D. Provide the client with non-slip bath strips in the bathtub.

Correct Answer is D

Explanation

A. The duration of time in the bathtub should be based on the client's tolerance but should not exceed 20 minutes.
B. Water temperature should be warm but not excessively hot to avoid burns or discomfort.
C. Bath oils can make the bathtub slippery and increase the risk of falls. They should be avoided.
D. Providing non-slip bath strips enhances safety and helps prevent the client from slipping in the bathtub.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving chemotherapy. The nurse should identify that a client who has myelosuppression is at risk for which of the following conditions?

Correct Answer is D

Explanation

A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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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.)

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