A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take?

A. Prepare to initiate antibiotic therapy: Antibiotics may be necessary if aspiration pneumonia develops, but this is not an immediate nursing action. Medication initiation requires provider evaluation and a prescription, making this a delayed intervention.

B. Obtain a prescription for a chest x-ray: A chest x-ray may be ordered to confirm aspiration, but requesting this is not the nurse’s next priority. Immediate nursing interventions to protect the airway and prevent further complications must occur first.

C. Position the client on their side: Placing the client on their side helps prevent further aspiration and promotes drainage of secretions or feeding material from the airway. This is the safest immediate response after stopping the feeding.

D. Suction the client's orotracheal airway: Suctioning is appropriate if the client has visible secretions, is coughing ineffectively, or shows respiratory distress. However, the priority immediate action is to position the client to reduce aspiration risk before suctioning if needed.

A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.

B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.

C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.

D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.