Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?

Health-seeking behaviors related to expressed desire for better sleep

Impaired bed mobility related to presence of CPAP mask on face

Risk for impaired skin integrity related to tight-fitting mask on face

Risk for powerlessness related to inability to breathe regularly during sleep

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.

Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. The Agency for Healthcare Research and Quality is a federal agency that supports research and improvement of health care quality and safety, but it does not provide treatment guidelines for acetaminophen overdose.

Choice B reason: This is correct. The American Association of Poison Control Centers is a national organization that provides poison information and treatment recommendations through a network of poison centers. The nurse can call the poison center at 1-800-222-1222 to get expert advice on how to manage the patient who took 60 acetaminophen tablets.

Choice C reason: This is incorrect. The Centers for Disease Control and Prevention is a federal agency that monitors and prevents diseases and public health threats, but it does not provide treatment guidelines for acetaminophen overdose.

Choice D reason: This is incorrect. The Institute for Safe Medication Practices is a nonprofit organization that promotes safe medication practices and error prevention, but it does not provide treatment guidelines for acetaminophen overdose.

A. The patient frequently uses an alcohol-based sanitizer for hand hygiene. B. The patient takes acetaminophen 1000 mg every 4 hours around the clock. C. The patient takes alprazolam 0.25 mg every 8 hours. D. The patient rinses with a fluoride mouthwash after brushing the teeth.

Correct Answer is B

Explanation

Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.

Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.

Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 8 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.

Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.

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Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

Correct Answer is B

Explanation

Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

Correct Answer is B

Explanation

Which assessment findings lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours? (Select all that apply.)

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Where will the restraints be tied to the patient’s bed when the nurse is applying soft wrist restraints to the patient?

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A small amount of mercury was spilled on the floor after an old sphygmomanometer was broken. What is the priority action of the nurse?