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 D

Explanation

Choice A reason: Muscle strength and tone is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have musculoskeletal problems, but it does not indicate the risk of thermal injury.

Choice B reason: Limitations to range of motion is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have joint stiffness or pain, but it does not indicate the risk of thermal injury.

Choice C reason: Presence of rebound phenomenon is not the most important assessment for the nurse to perform prior to the application of a heating pad. It is a sign of peritoneal inflammation that occurs when pressure is released from the abdomen. It has nothing to do with the application of a heating pad.

Choice D reason: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. It indicates the client's ability to perceive heat and pain sensations. If the client has impaired neurosensory function, the nurse should avoid using a heating pad or use it with caution and frequent monitoring.

A. Offer a pair of non-skid socks. B. Place the chair by the bed. C. Support the client when rising. D. Determine how the client feels.

Correct Answer is C

Explanation

Choice A reason: Offering a pair of non-skid socks is not the most important action to implement next. The client may already have non-skid socks on, or may not need them if they are not walking. The priority is to prevent falls and injuries when transferring the client to the chair.

Choice B reason: Placing the chair by the bed is a necessary action to implement, but not the next one. The chair should already be by the bed before the nurse raises the head of the bed and moves the client to a sitting position. The next action is to help the client stand up and move to the chair.

Choice C reason: Supporting the client when rising is the best action to implement next. The client may be weak, dizzy, or unsteady after a week of bedrest, and may need assistance to stand up and sit down. The nurse should use proper body mechanics and a transfer belt if needed to support the client.

Choice D reason: Determining how the client feels is a relevant action to implement, but not the next one. The nurse should assess the client's vital signs, comfort, and tolerance of the activity after transferring the client to the chair. The next action is to ensure the client's safety and stability.

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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 assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

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?

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?

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The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

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The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

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?

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?

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?