A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor? (Select all that apply.)

A. Constipation

Constipation is not typically associated with obstructive sleep apnea. However, sleep disturbances and certain medications used to manage OSA may indirectly contribute to constipation in some cases.

B. Nausea

Nausea is not a common symptom of obstructive sleep apnea. While sleep disturbances may affect gastrointestinal function in some individuals, nausea is not a typical manifestation of OSA.

C. Headache

One of the common findings associated with obstructive sleep apnea (OSA) is headache. This occurs due to the repeated episodes of apnea (cessation of breathing) during sleep, which leads to intermittent hypoxia (low oxygen levels) and subsequent cerebral vasodilation. The vasodilation can trigger headaches, often described as morning headaches, upon waking up. These headaches are typically frontal and may be accompanied by other symptoms such as fatigue and irritability.

D. Hypotension

Hypotension (low blood pressure) is not a typical finding in obstructive sleep apnea. In fact, individuals with OSA are more likely to have hypertension (high blood pressure) due to the effects of repeated apnea episodes on the cardiovascular system, such as increased sympathetic activity and arterial stiffness.

A. Turn off the ventilator alarms before suctioning the client's airway.

This choice is incorrect because it goes against standard practice. Ventilator alarms are critical for monitoring the patient's respiratory status and detecting any issues with the ventilator or the patient's airway. Turning off alarms before suctioning can lead to missed alarms and potentially dangerous situations for the patient.

B. Provide mouth care every 10 to 12 hr with hydrogen peroxide.

This choice is incorrect because using hydrogen peroxide for mouth care is not recommended. Hydrogen peroxide can be irritating to the mucosa and may cause harm to the patient's oral tissues. Instead, gentle oral care with an appropriate solution, such as a mouthwash specifically designed for oral hygiene in ventilated patients, is preferred. Mouth care should also be provided more frequently than every 10 to 12 hours to maintain oral hygiene and prevent complications such as ventilator-associated pneumonia.

C. Place the head of the client's bed at 40° when supine.

This choice is correct. Proper positioning of the patient is crucial for optimizing ventilation and preventing complications such as aspiration and ventilator-associated pneumonia. Elevating the head of the bed to 40 degrees when the patient is in a supine position helps to minimize the risk of aspiration by promoting drainage of secretions away from the airway and improving lung expansion.

D. Reposition the client every 4 hr.

This choice is not directly related to care for clients receiving mechanical ventilation. While repositioning the patient every 4 hours is important for preventing pressure ulcers and maintaining skin integrity, it is not specific to mechanical ventilation care. However, it is still an important aspect of overall patient care, particularly for patients who are immobile or confined to bed for extended periods.