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.

Answer and Explanation

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.

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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.

A. Move the client to a private room, keep the door closed, and initiate droplet precautions. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Assist the client to recall everyone possibly exposed since the onset of symptoms. D. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

Correct Answer is A

Explanation

Choice A reason: This is the most immediate and important action to take to prevent the potential spread of COVID-19, especially in a healthcare setting where there is a risk of infecting others.

Choice B reason: While placing the swab in a biohazard bag is a standard procedure, it is not as critical as isolating the patient to prevent transmission.

Choice C reason: Assisting the client to recall contacts is important for contact tracing, but it is secondary to immediate infection control measures within the clinic.

Choice D reason: Educating the client on preventive measures is important, but it does not take precedence over immediate actions to prevent the spread of infection in the clinic.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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