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.
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Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A reason: Use of a commode close by to where the client spends most of his time can reduce the distance and time required for the client to reach the toilet, and thus prevent accidents and embarrassment. It can also promote the client's independence and dignity.
Choice B reason: Development of a toileting schedule can help the client to establish a routine and habit of voiding at regular intervals, and thus prevent the bladder from becoming too full or overactive. It can also reduce the risk of urinary tract infections and skin breakdown.
Choice C reason: Use of an external catheter is not recommended for older adults with dementia, as it can cause irritation, infection, and obstruction of the urinary tract. It can also increase the client's confusion and agitation, and interfere with his mobility and comfort.
Choice D reason: Bladder diary to be completed by the client's wife is not a direct intervention to manage the incontinence, but rather a tool to assess the pattern and severity of the problem. It can help the nurse to identify the possible causes and triggers of the incontinence, and to evaluate the effectiveness of the interventions. However, it may not be feasible or reliable for the client's wife to complete the diary, as she may have other responsibilities or difficulties in observing and recording the client's urinary habits.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals who have had a previous episode of Herpes Zoster (HZ), as long as they are not currently experiencing an acute outbreak. The vaccine can help prevent future recurrences of HZ, as well as reduce the risk of postherpetic neuralgia, a painful complication of HZ.
Choice B reason: This statement is correct because the zoster vaccine Shingrix is recommended for all individuals over age 50 that have no contraindications to the vaccine, such as a history of severe allergic reaction to any component of the vaccine, or a current severe immunodeficiency. The vaccine can help prevent HZ and its complications, which are more common and severe in older adults.
Choice C reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals with a chronic cardiac or respiratory condition, as long as they are not immunocompromised. The vaccine is not a live vaccine, so it does not pose a risk of causing or worsening the underlying condition. The vaccine can help protect the individuals from HZ and its complications, which can exacerbate their condition or interfere with their treatment.
Choice D reason: This statement is incorrect because the zoster vaccine Shingrix does not always prevent an individual from developing Herpes Zoster. The vaccine has a high efficacy rate of about 90%, but it is not 100%. The vaccine can reduce the severity and duration of HZ, as well as the risk of postherpetic neuralgia, if it does occur..
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