The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?

Elevate the head of the bed to a 45-degree angle.

Remove dentures or other oral appliance.

Lift and lock the side rails in place.

Apply the client's positive airway pressure device.

Answer and Explanation

The Correct Answer is D

A. Elevate the head of the bed to a 45-degree angle may be helpful for some clients with OSA, but the most crucial intervention for a client with OSA is ensuring the proper use of the positive airway pressure (PAP) device.

B. Remove dentures or other oral appliance is not a priority for clients with OSA unless specifically contraindicated by the healthcare provider. The main concern is ensuring the PAP device is in place to prevent airway obstruction.

C. Lift and lock the side rails in place is a general safety measure, but it is not as critical as ensuring the client has their PAP device applied.

D. Apply the client's positive airway pressure device is the most important intervention. The PAP device (e.g., CPAP or BiPAP) helps keep the airway open during sleep, preventing apneas and improving oxygenation. Ensuring the client has this device in place is the most essential action before leaving the client alone.

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Correct Answer is B

Explanation

A. Assess the client for signs of diminished circulation in the hands is unnecessary at this stage, as the primary concern is ensuring proper crutch fit and teaching safe use.

B. Proceed with teaching the client how to walk with the crutches is correct because a space of three finger-widths between the crutch and the axilla indicates proper crutch height. This prevents nerve damage and discomfort in the axilla.

C. Ask the client to sit down while the crutch length is adjusted is not needed since the crutches are already appropriately adjusted based on the observed spacing.

D. Confer with the physical therapist for correct crutch size is unnecessary because the nurse can confirm that the crutches are properly fitted based on standard guidelines.

A. Commend the client for her patience after a long wait in the admission process. B. Determine the client's decision about homologous blood transfusion. C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery. D. Obtain primary source of information from the head of the spiritual group.

Correct Answer is B

Explanation

A. Commend the client for her patience after a long wait in the admission process is not appropriate at this time. While acknowledging the client's feelings is important, it is not the most relevant or immediate intervention for this situation.

B. Determine the client's decision about homologous blood transfusion is the most important action. Jehovah's Witnesses generally refuse blood transfusions based on their religious beliefs. The nurse should assess the client’s wishes regarding blood transfusions to ensure informed consent and respect for her beliefs.

C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery is not the most immediate action. While spiritual support is important, the priority is addressing the client’s medical decisions, particularly regarding blood transfusions, which may impact her care.

D. Obtain primary source of information from the head of the spiritual group is unnecessary. The client herself is the primary source of information about her beliefs and preferences, and the nurse should focus on her individual decisions rather than seeking information from a religious leader.

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The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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