A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper CPAP use?

There is one finger width between the strap on the mask and the client's face.

The therapeutic dose of albuterol is being inhaled.

The mask fits loosely so air can escape from underneath.

The mask is secured over the client's mouth and the client's nose is uncovered.

Answer and Explanation

The Correct Answer is A

A. There is one finger width between the strap on the mask and the client's face is correct. A properly fitted CPAP mask should have a snug fit, with a space of about one finger width between the strap and the face to ensure adequate seal and comfort. A mask that is too tight can cause discomfort, while a loose mask may not provide the necessary pressure to treat sleep apnea.

B. The therapeutic dose of albuterol is being inhaled is incorrect. Albuterol is used for bronchodilation in conditions like asthma, but it is not related to CPAP use. CPAP is designed to provide positive pressure to keep the airways open, not to treat asthma or other respiratory issues directly.

C. The mask fits loosely so air can escape from underneath is incorrect. A loose fit would lead to air leakage, reducing the effectiveness of the CPAP therapy. The mask should fit securely to ensure the proper amount of air pressure is delivered during sleep.

D. The mask is secured over the client's mouth and the client's nose is uncovered is incorrect. For effective CPAP therapy, the mask should cover both the nose and mouth, unless the client specifically uses a nasal CPAP mask designed to deliver pressure only through the nose.

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Correct Answer is C

Explanation

A. "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals." is incorrect. Oxygen should not typically be increased during meals unless specifically prescribed by the provider. If the client has difficulty eating due to breathlessness, a more individualized plan is needed.

B. "Drink at least 240 milliliters of water during each meal." is incorrect. Clients with COPD may have difficulty breathing when consuming large amounts of fluids during meals. Overhydration could also worsen fluid retention in some cases. The amount of fluid should be tailored to the client’s needs and prescribed by the healthcare provider.

C. "Perform pulmonary hygiene 1 hour before meals." is correct. Pulmonary hygiene (such as postural drainage, coughing techniques, and deep breathing exercises) should be performed before meals to clear the airways and improve the ability to breathe while eating, preventing aspiration and difficulty breathing.

D. "Lie down for 30 minutes after eating." is incorrect. Lying down after eating can increase the risk of aspiration, especially in clients with COPD who may already have a compromised respiratory system. The client should be advised to remain upright after meals to prevent reflux and aspiration.

A. The client develops chest pain each time he talks about his partner. B. The client keeps a framed picture of his partner on the wall. C. The client reports he has no interest in dating. D. The client attends a grief support group twice each month.

Correct Answer is A

Explanation

A. The client develops chest pain each time he talks about his partner is an indication of complicated grief. The client’s experience of intense, physical symptoms like chest pain when discussing their partner suggests that the grief process may not be progressing and could indicate unresolved or complicated grief.

B. The client keeps a framed picture of his partner on the wall is a normal expression of grief. Keeping a picture of a lost loved one is common and doesn’t necessarily indicate complicated grief. It can be part of the natural grieving process.

C. The client reports he has no interest in dating is not necessarily a sign of complicated grief. It's common for people grieving to not have an interest in dating or forming new romantic relationships immediately after the loss, but it does not suggest a problem unless the client expresses prolonged avoidance of all social interaction.

D. The client attends a grief support group twice each month is a positive coping mechanism. Attending support groups shows the client is actively engaging with the grieving process and seeking support, which is part of healthy adjustment after a loss.

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A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper CPAP use?

Nursing Test Bank

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