A client with obstructive sleep apnea (OSA ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?
Apply the client's positive airway pressure device.
Elevate the head of the bed to a 45-degree angle.
Remove dentures or other oral appliance.
Lift and lock the side rails in place.
The Correct Answer is A
A. Applying the positive airway pressure (PAP) device is crucial for managing obstructive sleep apnea (OSA and ensuring the client receives continuous positive airway pressure during sleep to prevent airway obstruction.
B. Elevating the head of the bed may be helpful in managing OSA, but ensuring the client uses the PAP device takes precedence.
C. Removing dentures or other oral appliances may improve comfort but is not as essential as ensuring proper use of the PAP device.
D. Lifting and locking the side rails may be important for safety but is not directly related to managing OSA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 18%: This would be the correct percentage for one leg only.
B. 36%: According to the Rule of Nines in burn assessment, each leg (including the foot) accounts for 18% of the body surface area. Since both lower extremities are affected, it totals 36% body surface area.
C. 4%: This percentage is too low for the described injury.
D. 09%: This would not be enough even for one leg, as each leg is 18%.
Correct Answer is D
Explanation
A. Keep the bed in the lowest position and initiate seizure and fall precautions: While seizure and fall precautions may be necessary for safety, the client's symptoms, including right-sided weakness and sluggish speech, are indicative of a potential stroke rather than a seizure. Immediate intervention to assess for and treat possible stroke is critical.
B. Place an indwelling urinary catheter and measure strict intake and output: Although urinary management may be necessary, it is not the priority in this situation. The client's symptoms suggest a neurological issue that requires urgent assessment and intervention.
C. Maintain elevated positioning of the dependent joints on affected side: Elevating the dependent joints is a strategy used in managing conditions like stroke to prevent complications such as edema, but it does not address the immediate need for stroke assessment and intervention.
D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy: Correct! The client's presentation with right-sided weakness and sluggish speech suggests a possible ischemic stroke. Starting IV access and reviewing inclusion criteria for IV fibrinolytic therapy (tPA is crucial for timely intervention to restore blood flow and minimize neurological damage.
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