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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: This is a correct answer because continuing to monitor the client for signs of an infection is important to detect any recurrence or complication of MRSA infection. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious skin, soft tissue, bone, joint, or bloodstream infections. The nurse should assess the client's vital signs, wound appearance, pain level, and laboratory results.
Choice B reason: This is not a correct answer because calling the healthcare provider for a prescription for linezolid is not necessary unless the client has an active MRSA infection that requires treatment. Linezolid is an antibiotic that can be used to treat MRSA infections, but it has potential side effects and interactions that need to be considered. The nurse should not prescribe or administer antibiotics without a valid order.
Choice C reason: This is a correct answer because collecting multiple sets of blood cultures for MRSA screening is important to identify any asymptomatic bacteremia or sepsis that could result from MRSA infection. MRSA can enter the bloodstream through wounds, catheters, or surgical sites and cause life-threatening complications such as endocarditis, osteomyelitis, or pneumonia. The nurse should obtain blood samples from different sites and times and send them to the laboratory for analysis.
Choice D reason: This is a correct answer because placing the client on contact transmission precautions is important to prevent the spread of MRSA to other clients, staff, or visitors. Contact transmission precautions include wearing gloves and gowns when entering the client's room, using dedicated or disposable equipment, and performing hand hygiene before and after contact with the client or their environment.
Choice E reason: This is not a correct answer because obtaining a sputum specimen for culture and sensitivity is not relevant to the client's history of MRSA wound infection. Sputum culture and sensitivity is a test that can be used to diagnose respiratory infections caused by bacteria, fungi, or viruses. The nurse should only obtain a sputum specimen if the client has signs or symptoms of a respiratory infection, such as cough, fever, chest pain, or dyspnea.
Correct Answer is C
Explanation
Choice A: Remove the catheter and palpate the client's bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.
Choice B: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.
Choice C: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.
Choice D: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.
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