Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?

Remove dentures or other oral appliance.

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

Apply the client’s positive airway pressure device.

Put and lock the side rails in place.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Removing dentures or other oral appliances may help prevent airway obstruction but is not the most critical intervention for a client with severe obstructive sleep apnea (OSA)4.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention to maintain airway patency and prevent respiratory compromise in a client with severe obstructive sleep apnea (OSA)4.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not directly address the airway management needs of a client with severe obstructive sleep apnea (OSA)4.

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Correct Answer is B

Explanation

Choice A rationale
Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and could lead to errors or contamination.
Choice B rationale
Asking another nurse to witness the medication being discarded ensures proper documentation, accountability, and compliance with regulations.
Choice C rationale
Placing the vial with the remainder of the medication into a locked drawer does not address the need for proper documentation and labeling of the remaining medication.
Choice D rationale
Throwing the vial into the trash in the presence of another nurse is not appropriate as it does not ensure proper documentation, accountability, or safe storage of the remaining medication.

A. Active bowel sounds in the lower right quadrant. B. Contraction of the left pupil when light shines in the right eye. C. Basilar lung sounds that are diminished in the left lung. D. Capillary refill of 2 seconds in the lower right foot.

Correct Answer is C

Explanation

Choice A rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.
Choice B rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.
Choice C rationale
Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.

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Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is B

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is C

Explanation

What times should the nurse measure vital signs? Select all that apply.

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Patient Data Exhibits Review H and P, nurse’s notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

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Which assessment should the nurse document when charting by exception?