The nurse administers an opioid analgesic to an older adult postoperative client in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the client’s room?

Position the client to achieve their comfort.

Offer toileting and a sip of water.

Place side rails up x 4.

Instruct the client to ask for help before getting up.

None of the above.

Answer and Explanation

The Correct Answer is D

Choice A reason: Position the client to achieve their comfort is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Comfort is important, but not the priority in this situation.

Choice B reason: Offer toileting and a sip of water is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Toileting and hydration are important, but not the priority in this situation.

Choice C reason: Place side rails up x 4 is not the most important intervention, as it may not prevent the client from getting out of bed and falling. Side rails may also be considered a restraint, which can increase the risk of injury and agitation. Side rails are not a substitute for proper supervision and assistance.

Choice D reason: Instruct the client to ask for help before getting up is the most important intervention, as it can prevent the client from falling and injuring themselves. Opioid analgesics can impair the client's balance, coordination, and judgment, making them more prone to falls. The nurse should educate the client about the effects of opioids and the importance of asking for help before attempting to get out of bed.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement before leaving the client’s room.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: A nasogastric tube may be necessary for some patients with dysphagia, which is difficulty swallowing, but not for dysarthria, which is difficulty speaking.

Choice B reason: Stems from severe rheumatoid arthritis is false because dysarthria is caused by damage to the nerves or muscles that control speech, not by inflammation of the joints.

Choice C reason: Physical therapy can be beneficial is true because dysarthria can be improved by exercises that strengthen the speech muscles and improve coordination.

Choice D reason: Can affect the balance is false because dysarthria does not affect the vestibular system, which is responsible for balance and spatial orientation.

A. Wear sturdy open-toed shoes B. Monitor blood glucose levels before and after a walk C. Omit antidiabetic medication D. Prepare to administer insulin

Correct Answer is B

Explanation

Choice A reason: Wearing sturdy open-toed shoes is not a good idea for a person with diabetes, as it can expose the feet to injuries or infections that can be hard to heal. The nurse would advise the patient to wear well-fitting, closed-toe shoes that protect the feet and prevent blisters or ulcers.

Choice B reason: Monitoring blood glucose levels before and after a walk is a sensible instruction for a person with diabetes, as physical activity can lower blood glucose levels and affect the need for medication or insulin. The nurse would advise the patient to check his blood glucose levels before and after a walk, and adjust his food intake or medication accordingly.

Choice C reason: Omitting antidiabetic medication is a dangerous instruction for a person with diabetes, as it can cause hyperglycemia or high blood glucose levels that can lead to serious complications. The nurse would advise the patient to take his medication as prescribed, and consult his doctor if he needs to change his dosage.

Choice D reason: Preparing to administer insulin is an unnecessary instruction for a person with type 2 diabetes who is not on insulin therapy, as it can cause hypoglycemia or low blood glucose levels that can be life-threatening. The nurse would advise the patient to follow his doctor's recommendations on whether he needs insulin or not, and how to use it safely.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse administers an opioid analgesic to an older adult postoperative client in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the client’s room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements is true about dysarthria?

Correct Answer is C

Explanation

The nurse assists an older adult man who is diagnosed with type 2 diabetes mellitus to improve his glucose control. Which of the following instructions does the nurse give to this individual when he plans to walk more than usual in one day?

Correct Answer is B

Explanation

Hyperglycemia is harder to detect in older adults due to which of the following?

When teaching a client about foods that do not increase blood glucose, which should the nurse include?

Which assessment finding of an older adult living in an assisted-living facility indicates the highest risk for suicide?

Which disorder would the nurse suspect in a patient complaining of intense headaches, bloodshot eyes, and blurred vision? This is considered a medical emergency.

An older client who was recently admitted to the sub-acute setting after having a knee replacement, is very anxious and refuses to get out of bed, stating that it is too painful. Which intervention will the nurse implement?

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

An African American 58-year-old man in good health has a blood pressure of 120/73 mm Hg at his annual physical examination. Which of the following is the best goal for the nurse to use to assist him in maintaining his health and wellness into older age?

An older adult diagnosed with heart failure (HF) reports increasing dyspnea over 2 days. Which of the following should the nurse assess to help determine whether the client has adhered to prescribed therapy? (Select all that apply.)