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 ["A","B","E","F"]
Explanation
Choice A reason: Diaphoresis is a common symptom of hypoglycemia, as the body tries to increase blood flow and release adrenaline to raise blood sugar levels. The client may notice sweating on the face, palms, or underarms.
Choice B reason: Anxiety is a common symptom of hypoglycemia, as the low blood sugar affects the brain and nervous system. The client may feel nervous, restless, or fearful.
Choice C reason: Tachycardia is not a reliable symptom of hypoglycemia for this client, as he is taking metoprolol, a beta-blocker that lowers the heart rate. Metoprolol can mask the signs of hypoglycemia, such as palpitations, tremors, and increased heart rate.
Choice D reason: Impaired vision is not a reliable symptom of hypoglycemia for this client, as he is an older adult who may have other eye problems, such as cataracts, glaucoma, or macular degeneration. Impaired vision can also be caused by other factors, such as fatigue, stress, or medication side effects.
Choice E reason: Confusion is a common symptom of hypoglycemia, as the low blood sugar affects the brain and cognitive function. The client may have difficulty thinking clearly, remembering things, or making decisions.
Choice F reason: Dizziness is a common symptom of hypoglycemia, as the low blood sugar affects the balance and coordination. The client may feel lightheaded, faint, or unsteady.
Correct Answer is C
Explanation
Choice A reason: Call for someone to bring the sign is not the most important intervention, as it does not address the immediate safety needs of the client. The sign is only a visual reminder of the fall risk, but it does not prevent the client from getting out of bed without assistance.
Choice B reason: Ensure he can reach his personal items is not the most important intervention, as it does not address the potential reasons for the client to get out of bed. The personal items may not include the items that the client needs, such as a phone, a book, or a snack.
Choice C reason: Instruct the client to use the call bell for help is the most important intervention, as it can prevent the client from falling and injuring themselves. The call bell is a device that allows the client to communicate with the nurse and request for help when needed. The nurse should educate the client about the importance of using the call bell and the risks of getting out of bed without assistance.
Choice D reason: Provide a urinal and drinking water is not the most important intervention, as it does not address the possible causes of the client's fall. The client may not need to use the urinal or drink water at the moment, or they may have other needs that are not met by these items.
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 to prevent this event.
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