A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?
Elevate the head of the bed to a 45 degree angle.
Lift and lock the side rails in place.
Apply the client's positive airway pressure device.
Remove dentures or other oral appliance.
The Correct Answer is C
A. Elevate the head of the bed to a 45-degree angle:
Elevating the head of the bed can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. While this intervention is important, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.
B. Lift and lock the side rails in place:
Ensuring the safety of the client by lifting and locking the side rails is important, but it does not directly address the client's OSA or the potential respiratory depression associated with opioid analgesic administration.
C. Apply the client's positive airway pressure device:
This is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.
D. Remove dentures or other oral appliance:
While removing dentures or other oral appliances may be necessary for client comfort and safety, it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Capillary refill of 2 seconds in the lower right foot:
Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.
B. Basilar lung sounds that are diminished in the left lung:
Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.
C. Contraction of the left pupil when light shines in the right eye:
Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.
D. Active bowel sounds in the lower right quadrant:
Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.
Correct Answer is C
Explanation
A. Speak loudly and face the client:
While it's important for the nurse to speak clearly and ensure the client can see their face, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.
B. Provide a very well-lit meeting space:
Ensuring adequate lighting is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.
C. Use everyday language when explaining issues:
This is the most important action. Using everyday language, free of medical jargon, ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.
D. Underline key words on the written information:
This can be a helpful strategy for emphasizing important points in written materials, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading. Therefore, oral communication in understandable language is paramount.
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