The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Remove dentures or other oral appliances.

Lift and lock the side rails in place.

Apply the client's positive airway pressure device.

Elevate the head of the bed to a 45-degree angle.

Answer and Explanation

The Correct Answer is C

Choice A reason: Removing dentures or other oral appliances may be necessary for some medical procedures, but it is not the most important intervention for a client with OSA who has just received an opioid patch.

Choice B reason: Lifting and locking the side rails in place is a standard safety measure, but it does not directly address the respiratory concerns associated with OSA and opioid use.

Choice C reason: Applying the client's positive airway pressure device is the most important intervention. Opioids can depress respiration, and for a client with OSA, ensuring the airway is patent and supported by a positive airway pressure device is crucial to prevent respiratory complications.

Choice D reason: Elevating the head of the bed can aid in respiration, but it is not as immediately critical as ensuring the use of a positive airway pressure device for a client with OSA who is receiving opioids.

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Correct Answer is B

Explanation

Choice A reason:Deferring to the provider does not address the confidentiality issue; it suggests the nurse is unwilling rather than clarifying the legal obligation to protect an adult client’s health information.

Choice B reason: By stating that only the client can authorize release of their own medical data, the nurse accurately reflects HIPAA and patient‑privacy regulations for an adult. This response both informs the parent and upholds the client’s right to confidentiality.

Choice C reason: This response is inappropriate and unprofessional. It fails to acknowledge the parent's concern and does not provide a constructive way to address the situation.

Choice D reason: While this response may seem helpful, it is not the nurse's role to promise lab results, especially when there are privacy laws that restrict the sharing of medical information with anyone other than the patient unless consent has been given.

A. Assess for discomfort when the procedure is completed. B. Instruct the client to keep hands under the sterile field. C. Pour cleansing solution onto the sterile cloth field. D. Verify that the client has given informed consent.

Correct Answer is B

Explanation

Choice A reason: Waiting until after the procedure to assess for discomfort does not ensure client safety during the procedure itself. While pain assessment is important, it is not the priority safety intervention in this situation, especially since the client is already mildly confused and could disrupt the sterile field or injure themselves if not properly guided.

Choice B reason: Because the client is mildly confused, there is a risk of them inadvertently reaching into or touching the sterile field during the procedure. The nurse’s priority safety action is to provide clear, simple instructions such as reminding the client to keep their hands away or under the sterile field. This prevents contamination and reduces the risk of infection, protecting both the client and the procedure.

Choice C reason: Pouring cleansing solution onto the sterile cloth field would contaminate the sterile setup, since fluids should only be poured into sterile containers or basins. This action could compromise the sterile field and increase infection risk, making it unsafe practice.

Choice D reason: Informed consent for a procedure like wound debridement must be obtained by the healthcare provider before the procedure begins, not during. While the nurse can verify consent earlier, at the point described in the scenario (when the sterile field is already set up), the immediate priority is to maintain sterility and safety, not obtain consent.

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The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

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