The nurse receives orders for an opiate pain medication for a client with severe pain. What other order does the nurse anticipate getting?
Fluid restriction by mouth
A low salt diet
A chest x-ray
Stool softener medication
Antidiarrheal medication
The Correct Answer is D
A. Fluid restriction by mouth is not typically necessary with opioid administration unless other health conditions require it.
B. A low salt diet is unrelated to opioid administration unless there are concurrent health issues like hypertension or fluid retention.
C. A chest x-ray is not indicated solely due to opioid use.
D. Stool softener medication is commonly prescribed alongside opioid medications because opioids frequently cause constipation due to reduced gastrointestinal motility.
E. Antidiarrheal medication is not needed, as opioids are more likely to cause constipation rather than diarrhea.
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Correct Answer is B
Explanation
A. This option incorrectly includes the aortic valve rather than the tricuspid valve in the S1 heart sound.
B. S1 represents the closure of the mitral and tricuspid valves, which occurs at the beginning of ventricular systole and produces the "lub" sound.
C. The pulmonic valve closure is associated with the S2 heart sound, not S1.
D. The closure of the pulmonic and aortic valves occurs in S2, not S1.
E. This combination is incorrect, as S1 is associated with mitral and tricuspid valve closure.
Correct Answer is A
Explanation
A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.