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 B
Explanation
This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.
Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.
Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.
Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.
Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.
Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.
Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.
Correct Answer is B
Explanation
Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.
This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.
Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.
Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.
Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.
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