Take full exam for free

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

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 C

Choice A rationale

Elevating the head of the bed to a 45-degree angle can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. However, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.

Choice B rationale

Lifting and locking the side rails in place ensures the safety of the client but does not directly address the client’s OSA or the potential respiratory depression associated with opioid analgesic administration.

Choice C rationale

Applying the client’s positive airway pressure device is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.

Choice D rationale

Removing dentures or other oral appliances may be necessary for client comfort and safety, but it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Verify placement of pulse oximeter. B. Increase the oxygen to 3 L/minute. C. Switch to a non-rebreather mask. D. Remove nasal cannula. E. Remove nasal cannula.

Correct Answer is A

Explanation

Choice A rationale

Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.

Choice B rationale

Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.

Choice C rationale

Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.

Choice D rationale

Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.

A. Risk for infection. B. Self-care deficit. C. Impaired physical mobility. D. Risk for impaired skin integrity.

Correct Answer is D

Explanation

Choice A rationale

Risk for infection is a concern for clients with neuropathy, as they may have reduced sensation and be unaware of injuries that can become infected. However, the primary concern in promoting foot care is preventing the occurrence of wounds or skin breakdown in the first place.

Choice B rationale

Self-care deficit is relevant for clients with neuropathy who may have difficulty performing foot care independently. However, the priority is to prevent skin breakdown and wounds, which can lead to more severe complications.

Choice C rationale

Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and ensuring proper foot care to avoid complications.

Choice D rationale

Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.
Preventing skin breakdown and maintaining skin integrity is crucial in this scenario.

Take full exam for free

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Free Nursing Test Bank

Correct Answer is A

Explanation

Correct Answer is D

Explanation

Quick Links

Resources

Take full exam for free A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Free Nursing Test Bank

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is D

Explanation

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?

Which client assessment should the nurse perform during nasopharyngeal suctioning?

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt and curses at the nurse. Which response is best for the nurse to provide?

The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Quick Links

Resources

Take full exam for free

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?