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: Paper mask and gown are considered regulated medical waste, which means they are contaminated with blood, body fluids, or microorganisms that pose a potential risk of infection¹. Therefore, they should be placed in a designated biohazard bag before they are removed from the room and treated according to the facility's policies and procedures².

Choice B reason: The nurse's stethoscope is not a disposable item and does not need to be placed in a biohazard bag. However, it should be cleaned and disinfected after each use to prevent cross-contamination³.

Choice C reason: Bed linens are not classified as regulated medical waste unless they are soaked with blood or body fluids¹. They can be placed in a regular laundry bag and washed according to the facility's guidelines.

Choice D reason: Sputum specimen is a type of microbiology laboratory waste, which is regulated medical waste¹. However, it should not be placed in a biohazard bag, but in a leak-proof, puncture-resistant container that is labeled with a biohazard symbol. This ensures the safe transport and handling of the specimen.

A. Inject in the abdominal area at least 2 inches from the umbilicus. B. Expel the air in the prefilled syringe prior to injection. C. Rotate injections between the abdomen and gluteal areas. D. Massage the injection site to increase absorption.

Correct Answer is A

Explanation

Choice A reason: This is the correct instruction as it ensures that the injection is given in a well-perfused area with minimal risk of injury to major blood vessels or organs. The umbilicus should be avoided as it may harbor bacteria or cause discomfort.

Choice B reason: This is an incorrect instruction as it may result in a loss of medication or inaccurate dosing. The air bubble in the prefilled syringe should be left intact as it helps to seal the medication in the subcutaneous tissue and prevent leakage.

Choice C reason: This is an incorrect instruction as it may cause irritation or inflammation of the injection sites. The gluteal area should be avoided as it has a higher risk of hitting a nerve or blood vessel. The abdomen is the preferred site for low-molecular-weight heparin injections.

Choice D reason: This is an incorrect instruction as it may increase the risk of bleeding or bruising. The injection site should not be massaged or rubbed as it may dislodge the clot or damage the tissue.

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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

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?

Correct Answer is A

Explanation

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

Correct Answer is A

Explanation

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