The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Lift and lock the side rails in place.

Apply the client's positive airway pressure device.

Elevate the head of the bed to a 45-degree angle.

Remove dentures or other oral appliances.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because lifting and locking the side rails in place is a standard safety measure for all clients, but it does not address the specific risk of respiratory depression caused by morphine and OSA.

Choice B Reason: This is correct because applying the client's positive airway pressure device can help maintain airway patency and prevent hypoxia and hypercapnia, which are common complications of OSA and opioid use.

Choice C Reason: This is incorrect because elevating the head of the bed to a 45-degree angle can help reduce chest pain and dyspnea, but it does not prevent airway obstruction or respiratory depression.

Choice D Reason: This is incorrect because removing dentures or other oral appliances can help prevent aspiration, but it does not affect the client's breathing pattern or oxygenation.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.

Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

A. Wait for notification that the system has been rebooted. B. Identify information as late entry in the record. C. Notify information services department of the situation. D. Print electronic medical record (EMR) from backup server.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because waiting for notification that the system has been rebooted can delay the client's care and compromise safety. The nurse should report the problem as soon as possible and use alternative methods of documentation.

Choice B Reason: This is incorrect because identifying information as late entry in the record is a secondary action that should be done after the system is restored. The nurse should prioritize resolving the technical issue and ensuring continuity of care.

Choice C Reason: This is correct because notifying information services department of the situation is the first action that the nurse should take to alert the experts who can troubleshoot and fix the problem. The nurse should also follow the facility's policy and procedure for documenting in a downtime situation.

Choice D Reason: This is incorrect because printing electronic medical record (EMR) from backup server may not be feasible or accessible depending on the extent of the system failure. The nurse should use paper forms or charts as a temporary measure until the system is back online.

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The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

Correct Answer is A

Explanation

The nurse is entering prescriptions for lab work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

Correct Answer is C

Explanation

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Patient Data Exhibits Review H and P and nurse's notes. Identify from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.