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 A

Explanation

A. Place the wheelchair on the client's left side is the most appropriate action. Since the client has right-sided hemiplegia, the nurse should place the wheelchair on the client's left side to allow for easier transfer. The left side is the stronger side, and the client will be able to use this side to assist with the transfer.

B. Instruct the client to take slow, deep breaths while transferring may help with relaxation, but it is not the priority in this scenario. The focus should be on positioning and safety during the transfer.

C. Instruct the client to look at his feet is not advisable because it may disrupt the client's balance or lead to a fall. The client should focus on using the stronger side to assist with the transfer.

D. Have the client put both arms around the nurse's neck for support is not safe and could cause strain or injury to both the client and the nurse. The client should be instructed to use proper body mechanics and rely on the nurse for support during the transfer, but not in a way that could lead to injury.

A. Administer a PRN sedative prescription. B. Leave the door to the client's room open slightly. C. Provide a back rub at bedtime. D. Apply wrist restraints to prevent wandering.

Correct Answer is C

Explanation

A. Administer a PRN sedative prescription should not be the first intervention. Non-pharmacological measures, such as promoting relaxation, should be attempted before resorting to medications.

B. Leave the door to the client's room open slightly can help with orientation but does not directly address the client's need for relaxation or sleep.

C. Provide a back rub at bedtime is a non-invasive, calming intervention that can help the client relax and promote sleep. It is appropriate to try this first before escalating to other measures.

D. Apply wrist restraints to prevent wandering is a last resort and should only be used when all other interventions have failed and the client poses a risk to themselves or others. Restraints are not indicated in this scenario without further justification.

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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 male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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