The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).
Which interaction is most important for the nurse to implement before leaving the client?

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

Apply the client's positive airway pressure device

Lift and lock the side rails in place

Remove dentures or other oral appliances

Answer and Explanation

The Correct Answer is B

The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep 1.

Choice A is not the answer because elevating the head of the bed to a 45-degree angle may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

Choice C is not the answer because lifting and locking the side rails in place is a safety measure but does not directly address the client’s OSA 1.

Choice D is not the answer because removing dentures or other oral appliances may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

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Correct Answer is C

Explanation

The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.

Choice A is not the answer because it is rude and unprofessional.

Choice B is not the answer because it does not address the issue of privacy and confidentiality.

Choice D is not the answer because it does not address the issue of privacy and confidentiality.

A. Ask the UAP to offer back rubs to the client. B. Reassess the client and the level of pain. C. Encourage the client to focus on taking deep breaths. D. Tell the client the medication needs more time to work.

Correct Answer is B

Explanation

The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.

Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.

Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.

Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.

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The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).
Which interaction is most important for the nurse to implement before leaving the client?