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 C

Explanation

Choice A reason: This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B reason: This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C reason: This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D reason: This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

A. Urine specific gravity B. Serum hematocrit C. Pulse rate D. Urinary output

Correct Answer is D

Explanation

Choice A reason: Urine specific gravity is a measure of the concentration of solutes in the urine. It is inversely related to the hydration status of the client. A high urine specific gravity indicates dehydration, while a low urine specific gravity indicates overhydration.

Choice B reason: Serum hematocrit is a measure of the percentage of red blood cells in the blood. It is also inversely related to the hydration status of the client. A high serum hematocrit indicates dehydration, while a low serum hematocrit indicates overhydration.

Choice C reason: Pulse rate is a measure of the frequency of the heartbeats. It is directly related to the hydration status of the client. A low pulse rate indicates dehydration, while a high pulse rate indicates overhydration.

Choice D reason: Urinary output is a measure of the amount of urine produced by the kidneys. It is directly related to the hydration status of the client. A low urinary output indicates dehydration, while a high urinary output indicates overhydration.

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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

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Correct Answer is C

Explanation

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

Correct Answer is D

Explanation

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The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

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