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","D","E"]

Explanation

Choice A: Lead the client in guided imagery

This is a correct choice because guided imagery is a non-pharmacological intervention that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system.

Choice B: Give a dose of 2.5 mg of Morphine

This is an incorrect choice because morphine is an opioid analgesic that can cause respiratory depression, hypotension, and bradycardia. The client's heart rate is already elevated, which could indicate inadequate pain relief or anxiety. Giving more morphine could worsen the client's condition and mask the underlying cause of the pain.

Choice C: Assist the client to walk around the room

This is an incorrect choice because walking around the room could increase the client's pain and heart rate by stimulating the sympathetic nervous system. The client has already done ambulation exercises with physical therapy at 1200, so there is no need to repeat them at 1400. The client should be allowed to rest in bed and conserve energy.

Choice D: Assess for sources of pain other than the surgical site

This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain.

Choice E: Consult with the surgeon about the pain level

This is a correct choice because the nurse should collaborate with the surgeon and other members of the health care team to provide optimal pain management for the client. The nurse should report the client's pain score, vital signs, medication administration, and response to interventions. The surgeon may order additional tests or medications to address the cause of the pain and improve the client's comfort.

A. Positions the head with the chin tilted slightly downward. B. Raises the head of the bed to 60 degrees. C. Places food on the unaffected side of the mouth. D. Allows 30 minutes of rest before feeding.

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.

Choice B Reason: This is incorrect because raising the head of the bed to 60 degrees can help prevent aspiration by using gravity to keep food in the stomach and away from the lungs.

Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.

Choice D Reason: This is correct because allowing 30 minutes of rest before feeding can increase the risk of aspiration by reducing the client's alertness and coordination. The UAP should feed the client when he or she is awake and responsive.

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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

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is D

Explanation

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