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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage.
B. Decreased skin turgor is incorrect. Skin turgor is an indicator of hydration status and is not directly related to compartment syndrome.
C. Pain relieved by analgesia is incorrect. One of the hallmark signs of compartment syndrome is severe pain that is not relieved by analgesia and worsens with passive movement.
D. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment.
E. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.
Correct Answer is D
Explanation
A. Leaving noninvasive equipment on the client’s body is not appropriate during postmortem care. Tubing and devices should be removed unless an autopsy is required.
B. Dentures should generally be left in place to maintain the natural shape of the face and promote a more normal appearance for family viewing.
C. Turning the lights up is unnecessary and may create a harsh environment. A calm, respectful setting with normal or dim lighting is preferred during postmortem care.
D. Closing the client’s eyes before the family views the body helps provide a peaceful and dignified appearance and is an important part of postmortem care.
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