A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

Apply the client's positive airway pressure device.

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

Remove dentures or other oral appliances.

Lift and lock the side rails in place.

Answer and Explanation

The Correct Answer is A

Choice B reason: Elevating the head of the bed to a 45-degree angle is not a sufficient intervention for the nurse to implement before leaving the client. Elevating the head of the bed can help reduce snoring and improve breathing by preventing the tongue and soft palate from falling back and obstructing the airway. However, it may not be enough to prevent apnea episodes in clients with obstructive sleep apnea, especially if they have other risk factors such as obesity, enlarged tonsils, or nasal congestion. The nurse should also use other interventions such as a positive airway pressure device, weight loss, or surgery.

Choice C reason: Removing dentures or other oral appliances is not a relevant intervention for the nurse to implement before leaving the client. Dentures or other oral appliances are devices that replace missing teeth or improve dental alignment. They may help improve speech, chewing, and appearance, but they do not have a direct impact on obstructive sleep apnea. The nurse should instruct the client to remove dentures or other oral appliances before going to bed to prevent discomfort, infection, or damage.

Choice D reason: Lifting and locking the side rails in place is not a necessary intervention for the nurse to implement before leaving the client. Side rails are bars that attach to the sides of the bed frame to prevent falls or injuries. They may provide safety and security for some clients, but they may also pose risks such as entrapment, strangulation, or agitation. The nurse should assess the need for side rails on an individual basis and consider alternative measures such as bed alarms, low beds, or floor mats.

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Correct Answer is C

Explanation

Choice A: Yellow-tinged sputum is not a serious adverse effect of linezolid. It may indicate an infection or inflammation in the respiratory tract, but it does not require immediate attention from the health care provider.

Choice B: Nausea and headache are common side effects of linezolid. They are usually mild and self-limiting, and they can be managed with supportive measures such as hydration, rest, and analgesics.

Choice C: Watery diarrhea is a sign of pseudomembranous colitis, a potentially life-threatening complication of linezolid. It is caused by an overgrowth of Clostridium difficile bacteria in the colon, which produce toxins that damage the intestinal mucosa. It can lead to dehydration, electrolyte imbalance, sepsis, and perforation. The nurse should report this finding to the health care provider immediately and stop the linezolid infusion.

Choice D: Increased fatigue is not a specific or serious adverse effect of linezolid. It may be related to the underlying infection, anemia, or other factors. It does not require urgent intervention from the health care provider.

A. Explain to the client that the dosage has been changed. B. Withhold the medication until the dosage can be confirmed. C. Inform him that he may refuse the medication and document whether or not he takes it. D. Tell him to take the medication then verify the dosage at the next healthcare team meeting.

Correct Answer is B

Explanation

Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.

Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.

Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.

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A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

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