A geriatric patient received a narcotic analgesic before leaving the post-anesthesia care unit to return to the regular unit.
What is the priority nursing action for the nurse receiving the patient on the regular unit?
Administer a non-steroidal anti-inflammatory drug.
Put side rails up and place bed in the lowest position.
Encourage fluids.
Create a restful dark environment.
The Correct Answer is B
Choice A rationale
Administering a non-steroidal anti-inflammatory drug (NSAID) is not a priority action for a patient who has received a narcotic analgesic. The priority should be to ensure the patient’s safety and prevent falls, which can occur due to the sedative effects of narcotics.
Choice B rationale
Putting side rails up and placing the bed in the lowest position is essential for patient safety. Narcotics can cause dizziness, drowsiness, and impaired coordination, increasing the risk of falls. Ensuring the bed is in the lowest position and side rails are up helps prevent injury if the patient tries to get up.
Choice C rationale
Encouraging fluids is beneficial for many patients, but it is not the priority action when a patient has received a narcotic analgesic. Hydration is important but secondary to ensuring the patient’s immediate safety.
Choice D rationale
Creating a restful, dark environment may help the patient rest, but it does not directly address the immediate safety needs of a patient who has received a narcotic analgesic. The focus should be on preventing falls and injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Itching and rash are not common adverse effects associated with calcium-channel blockers. They are more commonly related to other classes of medications.
Choice B rationale
Hypertension and tachycardia are not typical adverse effects of calcium-channel blockers. These medications are usually prescribed to treat hypertension and can actually cause a reduction in heart rate.
Choice C rationale
Nausea and diarrhea are possible side effects of many medications, but they are not specific adverse effects commonly linked to calcium-channel blockers.
Choice D rationale
Headache and dizziness are common adverse effects of calcium-channel blockers. These medications can cause vasodilation, leading to headaches and a decrease in blood pressure, which may result in dizziness, especially when standing up quickly. .
Correct Answer is D
Explanation
Choice A rationale
This choice is incorrect. A complete occlusion of a coronary vessel results in a myocardial infarction (heart attack), not unstable angina. Unstable angina occurs when there is a significant narrowing or partial blockage of a coronary artery, leading to reduced blood flow and oxygen supply to the heart muscle, causing pain or discomfort. Complete occlusion would cause permanent damage to the heart muscle, which is not the case with unstable angina.
Choice B rationale
This choice is correct. While unstable angina is mainly caused by narrowing of the coronary arteries, it can also be caused by a spasm of the blood vessel. This spasm, also known as vasospasm, reduces the amount of blood flow to the heart muscle, resulting in pain. These spasms can occur even if the coronary arteries do not have significant plaque buildup, adding another layer of complexity to the condition.
Choice C rationale
This choice is partially correct. The body’s response to a lack of oxygen (ischemia) in the heart muscle does result in pain, known as angina. However, this choice does not fully capture the specific nature of unstable angina, which involves episodes of pain that occur more frequently and are more severe than those associated with stable angina, and can occur at rest or with minimal exertion, indicating a higher risk for a heart attack.
Choice D rationale
This choice is correct. Unstable angina is characterized by a serious narrowing of a coronary artery that reduces oxygen supply to the heart. This narrowing is typically due to atherosclerotic plaque and can be complicated by blood clots or spasms. Unlike stable angina, the pain of unstable angina is more unpredictable and can occur without a triggering factor like exercise or stress, signaling a higher risk of a heart attack.
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