The nurse is preparing to administer hydrocodone to a client admitted with urolithiasis who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Apply the client's positive airway pressure device.

Lift and lock the side rails in place.

Remove dentures, or other oral appliances.

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

Answer and Explanation

The Correct Answer is A

Choice A reason: Applying the client's positive airway pressure device is the most important intervention for the nurse to implement before leaving the client. It helps to prevent the collapse of the upper airway and maintain adequate ventilation and oxygenation. It also reduces the risk of respiratory depression and apnea that may be caused by the opioid analgesic.

Choice B reason: Lifting and locking the side rails in place is a safety measure for the nurse to implement before leaving the client, but not the most important one. It helps to prevent the client from falling or injuring themselves, but it does not address the client's respiratory status or the effect of the medication.

Choice C reason: Removing dentures, or other oral appliances is a comfort measure for the nurse to implement before leaving the client, but not the most important one. It helps to prevent the client from choking or aspirating on the foreign objects, but it does not improve the client's airway patency or ventilation.

Choice D reason: Elevating the head of the bed to a 45-degree angle is a supportive measure for the nurse to implement before leaving the client, but not the most important one. It helps to facilitate the client's breathing and drainage of secretions, but it does not prevent the obstruction of the airway or the respiratory depression that may occur with the opioid analgesic.

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Correct Answer is A

Explanation

Choice A reason: This is the best explanation as it describes the main goal of the log-rolling technique, which is to prevent twisting or bending of the spine. This is especially important for clients who have spinal injuries, surgeries, or disorders.

Choice B reason: Using two or three people is a part of the log-rolling technique, but it is not the purpose of it. It is a means to achieve the purpose of maintaining spinal alignment. It also ensures that the client is moved smoothly and gently.

Choice C reason: Working together can decrease the risk of back injury to the nurses, but it is not the purpose of the log-rolling technique. It is a benefit for the nurses, but not for the client. The nurse should focus on the client's needs and outcomes.

Choice D reason: Turning instead of pulling reduces the likelihood of skin damage, but it is not the purpose of the log-rolling technique. It is an advantage for the client, but not the main reason for using the technique. The nurse should explain how the technique affects the spine, not the skin.

A. Abdominal girth. B. Breath sounds. C. Bowel sounds. D. Vital signs.

Correct Answer is D

Explanation

Choice A reason: This is not the most important assessment because abdominal girth is not a reliable indicator of fecal impaction. Abdominal girth can vary depending on the client's body type, fluid status, and other factors.

Choice B reason: This is also not the most important assessment because breath sounds are not directly related to fecal impaction. Breath sounds can be affected by respiratory conditions, smoking, allergies, and other factors.

Choice C reason: This is another incorrect choice because bowel sounds are not the most important assessment either. Bowel sounds can be diminished or absent in clients with fecal impaction, but they can also be altered by other gastrointestinal disorders, medications, and dietary factors.

Choice D reason: This is the correct choice because vital signs are the most important assessment prior to initiating digital removal of a fecal impaction. Vital signs can indicate the client's hemodynamic status, pain level, and risk of complications such as vagal stimulation, perforation, or infection. The nurse should monitor the client's blood pressure, pulse, respirations, and temperature before, during, and after the procedure.

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The nurse is preparing to administer hydrocodone to a client admitted with urolithiasis who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

Correct Answer is A

Explanation

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Correct Answer is D

Explanation

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

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

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

A client who had surgery 3 days ago is sitting with the head of the 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)?

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?