Which finding in a client diagnosed with obstructive sleep apnea (OSA) would require a nurse to take immediate action?
Client difficult to arouse.
Blood pressure 142/92 mmHg.
Apneic periods lasting more than 10 seconds.
Oxygen desaturation to 90% when asleep.
The Correct Answer is A
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An idiosyncratic drug effect is an unpredictable and uncommon reaction to a drug that is not related to the dose, the pharmacology, or the patient’s allergy or intolerance. It may be caused by genetic factors, metabolic abnormalities, or interactions with other drugs or substances. An example of an idiosyncratic drug effect is paradoxical agitation or excitement after receiving a sedative.
B. A toxic drug effect is a harmful reaction to a drug that is related to the dose or the pharmacology of the drug. It may cause symptoms such as nausea, vomiting, drowsiness, confusion, or respiratory depression. A toxic drug effect is unlikely to cause agitation after receiving a sedative unless there is an overdose or a drug interaction that increases the level of the sedative in the blood.
C. An allergic drug response is an immunological reaction to a drug that is not related to the dose or the pharmacology of the drug. It may cause symptoms such as rash, itching, swelling, fever, or anaphylaxis. An allergic drug response is unlikely to cause agitation after receiving a sedative unless there is a severe anaphylactic reaction that affects the brain or the circulation.
D. An unexpected drug interaction is a modification of the effect of one drug by another drug or substance that is not predictable based on their pharmacology. It may cause an increase or a decrease in the efficacy or toxicity of one or both drugs. An unexpected drug interaction may cause agitation after receiving a sedative if there is a synergistic effect that enhances the central nervous system stimulation of another drug or substance (such as caffeine, cocaine, or amphetamines) or if there is an antagonistic effect that reduces the central nervous system depression of the sedative (such as flumazenil, naloxone, or physostigmine). However, these interactions are usually known and avoidable by checking the patient’s history and medication list.
Correct Answer is ["D"]
Explanation
Older adults do not have a different pain mechanism and do not feel it as much as younger individuals. This statement is false and indicates the need for further education regarding pain management in older adults.
Some possible explanations for the other choices are:
Choice A is true because older adults often fear becoming addicted to pain medications and may underreport or deny their pain.
Choice B is true because older adults often take numerous drugs that can cause interactions with pain medications and increase the risk of adverse effects.
Choice C is true because confusion and delirium can be a more common reaction to certain pain medications in the elderly, especially opioids and benzodiazepines.
Normal ranges for vital signs in older adults are similar to those in younger adults, except for blood pressure, which may be higher due to arterial stiffness. The normal range for blood pressure in older adults is 120/80 to 140/90 mm Hg.
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