The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?
Remove dentures or other oral appliances.
Lift and lock the side rails in place.
Apply the client's positive airway pressure device.
Elevate the head of the bed to a 45-degree angle.
The Correct Answer is C
Choice A reason: Removing dentures or other oral appliances may be necessary for some medical procedures, but it is not the most important intervention for a client with OSA who has just received an opioid patch.
Choice B reason: Lifting and locking the side rails in place is a standard safety measure, but it does not directly address the respiratory concerns associated with OSA and opioid use.
Choice C reason: Applying the client's positive airway pressure device is the most important intervention. Opioids can depress respiration, and for a client with OSA, ensuring the airway is patent and supported by a positive airway pressure device is crucial to prevent respiratory complications.
Choice D reason: Elevating the head of the bed can aid in respiration, but it is not as immediately critical as ensuring the use of a positive airway pressure device for a client with OSA who is receiving opioids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While obtaining a 12-lead electrocardiogram is important for monitoring cardiac function, it is not as frequent or specific as potassium monitoring for hyperkalemia management.
Choice B reason: Evaluating glucose levels is necessary due to the risk of hypoglycemia from insulin administration, but the priority is monitoring potassium levels in hyperkalemia.
Choice C reason: Monitoring intake and output is part of fluid balance management but is secondary to the critical need to monitor serum potassium levels.
Choice D reason: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.
Correct Answer is A
Explanation
Choice A reason: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.
Choice B reason: While medication adherence is important for a client with schizophrenia, it does not present an immediate life-threatening situation. The nurse can return this call after addressing more urgent safety concerns.
Choice C reason: Physical altercations at school are serious, but if the child is safe and not in immediate danger, this call can be returned following more urgent issues.
Choice D reason: Sexual dysfunction can significantly affect quality of life, but it is not an immediate safety concern. This call should be returned after more urgent calls have been addressed.
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