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A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?
- A. Remove dentures or other oral appliance.
- B. Elevate the head of the bed to a 45-degree angle.
- C. Apply the client’s positive airway pressure device.
- D. Put and lock the side rails in place.
Correct Answer: C
Rationale: CPAP prevents airway collapse.
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A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. 2+ edema of fingers and hands.
- B. Capillary refill time is 2 seconds.
- C. Blood pressure is 142/88 mm Hg.
- D. Radial pulse volume is 3+.
Correct Answer: A
Rationale: Edema distorts oximeter readings.
Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.
The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain, the client denies having any pain. Which intervention should the nurse implement first?
- A. Administer PRN oral pain medication.
- B. Ask the client what is causing the grimacing.
- C. Monitor the client’s nonverbal behavior.
- D. Review the pain medications prescribed.
Correct Answer: B
Rationale: Clarifying nonverbal cues ensures accuracy.
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?
- A. Inspects crutches to ensure rubber tips are intact.
- B. Practices bicep and triceps isometric exercises.
- C. Bears body weight on the palms of hands during the crutch gait.
- D. Progresses to foot touchdown and weight bearing of the affected leg.
Correct Answer: C
Rationale: Inspecting tips ensures safety.