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.
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
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it does not directly indicate an understanding of standard precautions, which emphasize hand hygiene as a primary measure.
Choice B rationale
Removing the needle before discarding used syringes is not recommended as it increases the risk of needlestick injuries. Standard precautions emphasize the safe disposal of sharps in puncture-resistant containers without manipulating the needle.
Choice C rationale
Donning a face mask before administering medication is not a standard precaution for handling syringes and needles. Standard precautions focus more on hand hygiene and the use of gloves when there is a risk of exposure to blood or body fluids.
Choice D rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the transmission of infections and is a clear indication of understanding standard precautions.
Correct Answer is A
Explanation
Choice A rationale
Reporting the client’s status to the healthcare provider is the appropriate action. The healthcare provider needs to be informed of the client’s death to provide further instructions and complete necessary documentation. This action ensures proper communication and adherence to protocols.
Choice B rationale
Asking the UAP to complete postmortem care is necessary, but it should be done after notifying the healthcare provider. The nurse must follow the proper sequence of actions to ensure all protocols are followed.
Choice C rationale
Beginning cardiopulmonary resuscitation (CPR) and calling a code is not appropriate because the client has a signed do not resuscitate (DNR) form. Performing CPR would go against the client’s wishes and legal documentation.
Choice D rationale
Notifying the family of the client’s death is important, but it should be done after reporting the client’s status to the healthcare provider. The healthcare provider may have specific instructions for communicating with the family and completing necessary documentation.