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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because hematocrit is a measure of the percentage of red blood cells in the blood, which can indicate anemia or polycythemia, but not infection.
Choice B Reason: This is correct because neutrophil count is a measure of the number of neutrophils, which are white blood cells that fight infection and inflammation. A high neutrophil count can indicate a bacterial infection, such as in the wound.
Choice C Reason: This is incorrect because serum potassium and sodium levels are measures of the electrolyte balance in the blood, which can indicate dehydration, fluid overload, or kidney dysfunction, but not infection.
Choice D Reason: This is incorrect because blood pH level is a measure of the acidity or alkalinity of the blood, which can indicate acidosis or alkalosis, but not infection.
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.
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