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. Clamping the urinary catheter prior to the collection is typically done with clean hands, as the nurse is preparing the catheter for specimen collection. Gloves are not required for this step, as long as proper hand hygiene is performed before and after.

B. Using the syringe to remove the specimen from the catheter is the correct time for the nurse to wear gloves. This step involves direct contact with potentially contaminated urine, and gloves are necessary to maintain infection control and protect the nurse from exposure to bodily fluids.

C. Recording the output on the flowsheet in the client's room does not require gloves, as this step does not involve direct contact with the urine. The nurse should perform proper hand hygiene before and after documenting the output.

D. Transporting the urine specimen to the laboratory does not require gloves, as the specimen is contained in a biohazard bag. Gloves are typically worn during the collection process, but transporting a properly sealed specimen does not require additional protection.

A. Check skin for unusual bruising. B. Palpate mucus membranes for cracks. C. Monitor color of nailbeds. D. Assess skin folds of perineal area. E. Observe skin under the breasts.

Correct Answer is ["D","E"]

Explanation

A. Check skin for unusual bruising is not directly related to the client's diaphoretic condition. While bruising may be relevant in some cases, it is not the priority in this scenario, where the focus is on managing moisture and skin integrity.

B. Palpate mucus membranes for cracks is not as relevant in this situation. Cracks in the mucus membranes could indicate dehydration or other issues, but the primary concern for a diaphoretic client is skin breakdown due to moisture.

C. Monitor color of nailbeds is important in general assessment, but it is not directly related to the client's diaphoretic condition. Nailbed color may indicate circulation issues, but it is not a primary concern for this scenario.

D. Assess skin folds of perineal area is important because moisture from perspiration can accumulate in skin folds, increasing the risk for skin breakdown or infection, especially in overweight clients.

E. Observe skin under the breasts is also critical. The skin under the breasts is prone to moisture buildup, which can lead to irritation, fungal infections, or skin breakdown in overweight clients. Regular assessment of this area is necessary to prevent complications.

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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

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is B

Explanation

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Correct Answer is ["D","E"]

Explanation

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