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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Providing oral sponge toothettes is the best action to take. It helps the client to maintain oral hygiene and comfort, and prevents dryness and cracking of the oral mucosa.
Choice B reason: Teaching the client that the oral mucosa must remain dry to prevent aspiration is not a correct action. The oral mucosa needs to be moist to protect it from infection and irritation. Aspiration is prevented by checking the placement of the nasogastric tube and keeping the head of the bed elevated.
Choice C reason: Turning the suction off while allowing the client to rinse his mouth with cool water is not a safe action. It may increase the risk of aspiration and interfere with the function of the nasogastric tube. The suction should only be turned off when necessary, such as during medication administration or tube feeding.
Choice D reason: Instilling 50 ml of normal saline solution into the tube and clamping the tube for one hour is not an appropriate action. It may cause fluid overload, electrolyte imbalance, and abdominal distension. The nasogastric tube should be flushed with 30 ml of water every 4 to 6 hours to maintain patency and prevent clogging.
Correct Answer is D
Explanation
Choice A reason: This is not the best intervention as it does not address the cause of the pain or provide adequate relief. Deep breathing may help the client to relax and cope with the pain, but it is not enough to manage severe pain.
Choice B reason: This is not a true or helpful statement as it may imply that the nurse is dismissing the client's pain or delaying further action. Oxycodone is a fast-acting opioid analgesic that reaches its peak effect within 30 to 60 minutes. If the client is still in severe pain after one hour, the nurse should reassess the pain and notify the healthcare provider.
Choice C reason: This is not the priority intervention as it does not address the cause of the pain or provide adequate relief. A backrub may help the client to relax and distract from the pain, but it is not enough to manage severe pain.
Choice D reason: This is the best intervention as it helps the nurse to evaluate the effectiveness of the medication and the need for further intervention. The nurse should use a valid and reliable pain assessment tool and ask the client about the location, intensity, quality, and duration of the pain. The nurse should also check the client's vital signs and observe for any signs of adverse effects from the medication.
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