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 appliance.

Lift and lock the side rails in place.

Answer and Explanation

The Correct Answer is A

A. Applying the positive airway pressure (PAP) device is crucial for managing obstructive sleep apnea (OSA and ensuring the client receives continuous positive airway pressure during sleep to prevent airway obstruction.
B. Elevating the head of the bed may be helpful in managing OSA, but ensuring the client uses the PAP device takes precedence.
C. Removing dentures or other oral appliances may improve comfort but is not as essential as ensuring proper use of the PAP device.
D. Lifting and locking the side rails may be important for safety but is not directly related to managing OSA.

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Correct Answer is C

Explanation

A. When the client has ankle edema Ankle edema may indicate fluid retention, which is common during pregnancy but is not directly related to the assessment of deep tendon reflexes (DTRs).

B. Within the first trimester of pregnancy: Assessing DTRs within the first trimester of pregnancy is not specifically indicated unless there are other signs or symptoms of concern.

C. If the client has an elevated blood pressure: Assessment of DTRs is particularly important if the client has an elevated blood pressure, as it may indicate preeclampsia, a serious pregnancy complication characterized by hypertension and proteinuria.

D. During admission to labor and delivery: While assessment of DTRs may be included in the admission assessment to labor and delivery, it is particularly important to assess DTRs if the client has an elevated blood pressure, as it may indicate preeclampsia.

A. Provide diet low in phosphorus. B. Note signs of swelling and edema. C. Increase oral fluid intake to 1,500 mL daily. D. Monitor abdominal girth. E. Report serum albumin and globulin levels.

Correct Answer is ["B","D","E"]

Explanation

A. A diet low in phosphorus is not typically indicated for cirrhosis of the liver. Cirrhosis primarily affects the body's ability to handle proteins and not phosphorus.
B. Noting signs of swelling and edema is important as these are common complications of cirrhosis due to hypoalbuminemia and portal hypertension.
C. Increasing oral fluid intake is not advised as it can exacerbate fluid retention and ascites, which are complications of cirrhosis.
D. Monitoring abdominal girth is crucial for assessing changes in ascites and potential fluid overload.
E. Reporting serum albumin and globulin levels is essential as these can indicate the severity of liver disease and help guide treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is C

Explanation

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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