The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions, as seen in the video.

What action(s) should the charge nurse take? (Select all that apply.)

Choice A reason: This is the correct answer because applying the client's positive airway pressure device is the most important intervention for the nurse to implement before leaving the client. Positive airway pressure device is a treatment that delivers pressurized air through a mask or nasal prongs to keep the upper airway open and prevent apnea episodes during sleep. Obstructive sleep apnea is a condition that causes repeated interruptions in breathing due to partial or complete collapse of the upper airway during sleep. The nurse should ensure that the device is fitted properly and functioning well.

Choice B reason: Elevating the head of the bed to a 45 degree angle is not a sufficient intervention for the nurse to implement before leaving the client. Elevating the head of the bed can help reduce snoring and improve breathing by preventing the tongue and soft palate from falling back and obstructing the airway. However, it may not be enough to prevent apnea episodes in clients with obstructive sleep apnea, especially if they have other risk factors such as obesity, enlarged tonsils, or nasal congestion. The nurse should also use other interventions such as positive airway pressure device, weight loss, or surgery.

Choice C reason: Removing dentures or other oral appliances is not a relevant intervention for the nurse to implement before leaving the client. Dentures or other oral appliances are devices that replace missing teeth or improve dental alignment. They may help improve speech, chewing, and appearance, but they do not have a direct impact on obstructive sleep apnea. The nurse should instruct the client to remove dentures or other oral appliances before going to bed to prevent discomfort, infection, or damage.

Choice D reason: Lifting and locking the side rails in place is not a necessary intervention for the nurse to implement before leaving the client. Side rails are bars that attach to the sides of the bed frame to prevent falls or injuries. They may provide safety and security for some clients, but they may also pose risks such as entrapment, strangulation, or agitation. The nurse should assess the need for side rails on an individual basis and consider alternative measures such as bed alarms, low beds, or floor mats.

Choice B reason: assessing the DTRs of a pregnant client with an elevated blood pressure can help detect signs of preeclampsia, a serious complication of pregnancy that can cause seizures, organ damage, and fetal death. Preeclampsia can cause hyperreflexia, which is an exaggerated response of the DTRs.

Choice A reason: ankle edema is not a reliable indicator of preeclampsia and does not require assessing the DTRs. Ankle edema is a common finding in normal pregnancy due to increased blood volume and fluid retention.

Choice C reason: assessing the DTRs during admission to labor and delivery is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs during admission to labor and delivery can help monitor the client's neurological status, but it is not a priority action.

Choice D reason: assessing the DTRs within the first trimester of pregnancy is not as important as assessing them if the client has an elevated blood pressure. Assessing the DTRs within the first trimester of pregnancy can help establish a baseline, but it is not a priority action.