A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the client on use of call light.

Apply an ambulation alarm to the client’s leg.

Apply restraints to the client PRN.

Raise the four side rails of the client’s bed.

Check on the client hourly

Answer and Explanation

Correct Answer : A,B,D,E

A.   Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B.   Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C.   Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D.   Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

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Correct Answer is D

Explanation

A. Avoids the child's question and deflects to a future topic.
B. Defers the conversation and may not address the child's immediate concerns.
C. Minimizes the child's feelings and concerns about the future.
D. Encourages open communication and allows the child to express feelings and fears.

Correct Answer is ["94"]

Explanation

To answer this question, we need to use the formula: mL/hr = total volume (mL) / total time (hr). In this case, the total volume is 750 mL and the total time is 8 hr.

Plugging these values into the formula, we get: mL/hr = 750 / 8. Simplifying this fraction, we get: mL/hr = 93.75.

Since we need to round to the nearest whole number, the final answer is: mL/hr = 94. Therefore, the nurse should set the IV pump to deliver 94 mL/hr.

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A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who has metastatic osteosarcoma. While the parents are away, the child is crying and asks the nurse if she is going to die. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

A nurse is preparing to administer 0.9% sodium chloride (NaCl) 750 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["94"]

Explanation

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