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
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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Related Questions
Correct Answer is D
Explanation
A. Cryosurgery involves freezing the lesion and is typically used for benign lesions.
Malignant melanoma often requires more extensive treatment.
B. Radiation therapy may be used in certain cases, but surgical excision is often the primary treatment for malignant melanoma.
C. Chemotherapy is not the primary treatment for localized malignant melanoma but may be used for advanced cases or metastatic disease.
D. Surgical excision is the primary treatment for localized malignant melanoma, aiming to remove the tumor along with a margin of normal tissue.
Correct Answer is ["10"]
Explanation
To answer this question, we need to use the formula:
mL = (dose ordered / dose available) x mL available
Plugging in the values from the question, we get:
mL = (50 mg / 25 mg) x 5 mL
mL = 2 x 5 mL
mL = 10 mL
Therefore, the nurse should administer 10 mL of hydroxyzine oral suspension.
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