A nurse is caring for a client who complains about sleep apnea.
Which delivery device would the nurse expect to use to administer oxygen to this client while sleeping?
CPAP mask.
Nasal cannula.
Non-rebreather mask.
Simple face mask.
The Correct Answer is A
Choice A rationale
A CPAP (Continuous Positive Airway Pressure) mask delivers a constant stream of pressurized air to keep the airway open during sleep, which is the primary treatment for sleep apnea. Sleep apnea is characterized by repeated pauses in breathing due to airway obstruction, and CPAP effectively prevents these episodes.
Choice B rationale
A nasal cannula delivers low-flow oxygen through two prongs inserted into the nostrils. While it can provide supplemental oxygen, it does not address the underlying airway obstruction that occurs in sleep apnea. Therefore, it is not the expected delivery device for this condition. Normal flow rate is 1 to 6 liters per minute, providing a fraction of inspired oxygen (FiO2) of 24% to 44%.
Choice C rationale
A non-rebreather mask delivers a high concentration of oxygen (60% to 90%) and is typically used for patients with acute respiratory distress. It is not the appropriate device for managing the chronic condition of sleep apnea, which primarily requires airway support rather than high oxygen levels.
Choice D rationale
A simple face mask delivers a moderate concentration of oxygen (40% to 60%) and requires a flow rate of 5 to 8 liters per minute. While it provides more oxygen than a nasal cannula, it does not address the airway obstruction inherent in sleep apnea and is therefore not the expected device for this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Before delegating any nursing task, the nurse must first determine if the action is permissible under the state's nurse practice act and the employing agency's policies. These regulations define the scope of practice for nurses and the tasks that can be safely and legally delegated to unlicensed personnel. If delegation is not allowed by these governing bodies, the subsequent questions become irrelevant.
Choice B rationale
While it is crucial to ensure that the UAP has been adequately trained and is competent to perform the delegated task safely and correctly, this consideration comes after establishing the legality and permissibility of the delegation according to the nurse practice act and agency policy. Training is important for safe implementation but not the initial determining factor.
Choice C rationale
Appropriate supervision is necessary when delegating tasks to UAPs to ensure client safety and provide guidance. However, the ability to delegate the task itself must first be established by legal and policy guidelines. Supervision is a component of safe delegation but not the primary question determining if delegation is even an option.
Choice D rationale
Evaluating the client's past response to a treatment might inform how the task is performed or any specific observations needed, but it does not determine the fundamental question of whether the task can be delegated to a UAP in the first place. Legal and policy frameworks dictate the scope of delegation, regardless of the client's history. .
Correct Answer is D
Explanation
Choice A rationale
While it might seem natural to inquire about prior discussions, this response could induce guilt or regret in the spouse and doesn't directly address the current emotional distress and uncertainty about the spouse's wishes as explicitly stated in the advance directive. It shifts the focus to the past rather than the present need for clarification regarding the existing directive.
Choice B rationale
Although the primary care provider may indeed have the client's best interests in mind, this statement dismisses the spouse's expressed uncertainty and relies on an assumption about the PCP's motivations. It doesn't help the spouse understand or feel confident about the content of the advance directive, which is the core of their concern.
Choice C rationale
This statement, while true, places the burden of decision-making solely on the spouse without acknowledging the existence of the advance directive, which is meant to guide such decisions. It overlooks the possibility that the directive already contains the spouse's wishes and could offer clarity, thereby increasing the spouse's anxiety.
Choice D rationale
This response directly addresses the spouse's statement by reminding them that their spouse's wishes are likely documented in the advance directive. It encourages the spouse to review the directive, which is the most direct way to understand what their spouse wanted regarding medical interventions like a PEG tube, thus providing immediate and relevant support.
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