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 C
Explanation
Choice A reason: Removing the nasal cannula is not appropriate as it would deprive the client of supplemental oxygen. The client's oxygen saturation is below the normal range of 95% to 100%, indicating hypoxemia.
Choice B reason:While increasing oxygen might seem appropriate, this should only be done after verifying the accuracy of the pulse oximeter reading and assessing the client’s overall condition. Automatically increasing oxygen without further assessment could delay addressing other underlying issues or lead to over-oxygenation in clients with certain conditions like COPD.
Choice C reason:The first step is to ensure the accuracy of the pulse oximeter reading by checking its placement and ruling out factors that can interfere with accurate readings, such as poor circulation, cold extremities, nail polish, or motion artifacts. This ensures that the subsequent intervention is based on reliable data.
Choice D reason: Switching to a non-rebreather mask is not necessary as it would deliver a high concentration of oxygen (up to 100%) that may be excessive for the client. A nasal cannula can deliver oxygen from 1 to 6 L/minute, depending on the client's needs.
Correct Answer is A
Explanation
Choice A reason: This is the correct action as it prevents the risk of spillage, scalding, or infection. The basin of water should not be placed on the bed, but on a bedside table or stand. The nurse should also check the temperature of the water and the condition of the client's foot.
Choice B reason: This is an incorrect action as it may cause irritation or allergic reaction. The skin cream should not be added to the basin of water, but applied after the foot is dried and inspected. The nurse should also verify the type and amount of skin cream to be used.
Choice C reason: This is an important action, but not the priority. The UAP should dry between the client's toes completely to prevent fungal growth or maceration. The nurse should also monitor the UAP's technique and provide feedback.
Choice D reason: This is an inaccurate statement. The procedure of soaking the client's foot in a basin of warm water is not damaging to the skin, if done properly and safely. The nurse should explain the rationale and benefits of the procedure to the UAP.
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