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 A

Explanation

A. Influenza vaccines are typically produced using eggs, and individuals with egg allergies may react to the vaccine. However, there are egg-free alternatives available, and consultation with an allergist is recommended in such cases.
B. Polio vaccines do not contain egg proteins and are safe for individuals with egg allergies.=
C. Hib vaccines are not contraindicated for individuals with egg allergies.
D. Hepatitis B vaccines do not contain egg proteins and are generally safe for individuals with egg allergies.

A. The client draws his legs up into a fetal position. B. The facial muscles relax. C. The respiratory rate increases. D. The shoulders droop. E. The pulse is within the expected range

Correct Answer is ["B","D","E"]

Explanation

A. Drawing legs up into a fetal position may indicate discomfort or agitation.
B. Facial muscle relaxation is indicative of a therapeutic response to the massage.
C. An increased respiratory rate may suggest distress or discomfort.
D. Drooping shoulders suggest relaxation and a positive response to the massage.
E. Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer immunizations to a patient who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations?

Correct Answer is A

Explanation

A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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