The nurse administers an opioid analgesic to an older male postoperative patient in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the pa-tient's room?

Question

a. Place side rails up x 4.
b. Position the patient comfortably.
c. Offer toileting and a sip of water.
d. Instruct him to ask for help before getting up.

Answer 1

D
The most important intervention for fall and injury prevention is for the nurse to instruct the older adult to ask for help before getting up after receiving an opioid medication. This intervention is important because the medication can cause sedation and dizziness; therefore the nurse instructs him to ask for help to prevent a fall or injury. Side rails up x 4 is considered a restraint and may place the patient at risk for injury. Comfortable positioning is also a good supplemental intervention after administering pain medication. Offering toileting and hydration is a reasonable intervention to implement after administering pain medication, but it does not offer the same de-gree of safety as instructing the patient to call for help.