The nurse administers an opioid analgesic to an older adult postoperative client in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the client’s room?
Position the client to achieve their comfort.
Offer toileting and a sip of water.
Place side rails up x 4.
Instruct the client to ask for help before getting up.
None of the above.
The Correct Answer is D
Choice A reason: Position the client to achieve their comfort is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Comfort is important, but not the priority in this situation.
Choice B reason: Offer toileting and a sip of water is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Toileting and hydration are important, but not the priority in this situation.
Choice C reason: Place side rails up x 4 is not the most important intervention, as it may not prevent the client from getting out of bed and falling. Side rails may also be considered a restraint, which can increase the risk of injury and agitation. Side rails are not a substitute for proper supervision and assistance.
Choice D reason: Instruct the client to ask for help before getting up is the most important intervention, as it can prevent the client from falling and injuring themselves. Opioid analgesics can impair the client's balance, coordination, and judgment, making them more prone to falls. The nurse should educate the client about the effects of opioids and the importance of asking for help before attempting to get out of bed.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement before leaving the client’s room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because any exertion on the part of an older adult with heart disease does not necessarily result in death. Exertion can increase the oxygen demand of the heart and cause angina, or chest pain, but it can also be beneficial for the cardiovascular health and fitness of the older adult, if done within the limits of their tolerance and under medical supervision.
Choice B reason: This is incorrect because myocardial infarction is not the same as heart attack, cardiac arrest, or coronary thrombosis, although they are related terms. Myocardial infarction is the medical term for the death of a part of the heart muscle due to lack of blood supply. Heart attack is the common term for myocardial infarction. Cardiac arrest is the sudden loss of heart function, which can be caused by myocardial infarction or other factors. Coronary thrombosis is the formation of a blood clot in a coronary artery, which can lead to myocardial infarction.
Choice C reason: This is correct because both excessive undernutrition and overnutrition can contribute to heart disease. Undernutrition can cause malnutrition, anemia, and low immunity, which can increase the risk of infections and inflammation that can damage the heart. Overnutrition can cause obesity, diabetes, and high cholesterol, which can increase the risk of atherosclerosis and hypertension that can impair the blood flow to the heart.
Choice D reason: This is incorrect because a person with diabetes should have their blood pressure checked regularly, but this is not a statement about heart disease in Kenya. Diabetes is a risk factor for heart disease, as it can damage the blood vessels and nerves that control the heart. However, this statement is applicable to any person with diabetes, regardless of their location.
Correct Answer is C
Explanation
Choice A reason: A licensed practical nurse is qualified to care for the feet of a client with diabetes is false because foot care for people with diabetes requires specialized training and skills that are beyond the scope of practice of a licensed practical nurse. A registered nurse or a podiatrist should provide foot care for people with diabetes, as they can assess, treat, and prevent foot problems such as ulcers, infections, or nerve damage.
Choice B reason: Onychomycosis is quickly eradicated with antifungal creams or powders is false because onychomycosis, or fungal nail infection, is a stubborn and persistent condition that can take months or years to clear. Antifungal creams or powders are usually not effective for onychomycosis, as they cannot penetrate the nail plate. Oral antifungal medication or laser therapy may be needed to treat onychomycosis.
Choice C reason: Maintaining oral hydration may reduce the incidence of xerosis is true because xerosis, or dry skin, is a common problem for older adults, as their skin produces less oil and moisture. Drinking enough fluids can help hydrate the skin and prevent dryness, itching, cracking, or infection. The recommended fluid intake for older adults is 2400 mL/day, according to the National Council on Aging.
Choice D reason: Ram’s-horn nail should be cut to give a smooth, rounded edge is false because ram’s-horn nail, or onychogryphosis, is a condition where the nail becomes thickened, curved, and distorted. Cutting the nail can be difficult and painful, and may cause bleeding or infection. A podiatrist should trim and file the nail, and treat any underlying causes of the condition.
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