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 B

Explanation

A. Diazepam can cause side effects, especially drowsiness, even with a single dose.
B. One of the common side effects of diazepam is drowsiness, and the client should be advised not to operate heavy machinery or engage in activities requiring alertness until the effects are known.
C. Avoiding foods that contain tyramine is more relevant for certain antidepressant medications, not diazepam.
D. Grapefruit juice is known to interact with certain medications, but it does not inactivate diazepam.

Correct Answer is ["0.6"]

Explanation

To calculate the dosage of diphenhydramine, the nurse needs to use the formula D/H x Q

= X, where D is the desired dose, H is the on-hand dose, Q is the quantity of the on-hand dose, and X is the amount to administer. In this case, D is 30 mg, H is 50 mg/mL, and Q is 1 mL. Plugging these values into the formula, we get:

30/50 x 1 = 0.6

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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 reinforcing teaching with a client who takes diazepam. Which of the following information should the nurse the nurse include?

Correct Answer is B

Explanation

Correct Answer is ["0.6"]

Explanation

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