A nurse is caring for a client who reports difficulty sleeping and has a new diagnosis of sleep apnea. Which of the following statements by the client should the nurse expect?
"I have headaches in the evening."
"I feel rested upon wakening."
"I feel alert during the day."
"My spouse says I snore."
The Correct Answer is D
A. "I have headaches in the evening.": Headaches associated with sleep apnea typically occur in the morning due to nocturnal hypoxia and carbon dioxide retention, not in the evening. Evening headaches are not a common presenting symptom.
B. "I feel rested upon wakening.": Clients with sleep apnea often experience non-restorative sleep and wake feeling tired or unrefreshed. Feeling rested upon waking would not be expected in untreated sleep apnea.
C. "I feel alert during the day.": Daytime sleepiness is a hallmark symptom of sleep apnea due to fragmented sleep and oxygen desaturation. Feeling alert would not align with the typical presentation.
D. "My spouse says I snore.": Loud, habitual snoring is a common and expected symptom of obstructive sleep apnea. It is often reported by bed partners and is an important clinical clue for diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I should expect my tears to turn a red color after using the eye drops.": Timolol does not cause red discoloration of tears. Redness of the eye may indicate irritation, allergy, or another adverse effect, so the client should report persistent redness rather than expect it as normal.
B. "I will put pressure on the corner of my eye after using the eye drops.": Applying gentle pressure to the nasolacrimal duct (inner corner of the eye) after instilling timolol reduces systemic absorption and potential systemic side effects, such as bradycardia or hypotension. This technique demonstrates proper administration and understanding of safety precautions.
C. "The drops should be placed in the center of my eye.": Eye drops should be instilled into the lower conjunctival sac, not directly onto the center of the cornea, to reduce irritation and maximize absorption. Placing drops on the cornea can cause discomfort and reduce effectiveness.
D. "These drops will improve my cloudy vision.": Timolol lowers intraocular pressure but does not restore vision or improve cloudiness caused by glaucoma. The goal of therapy is to prevent progression of vision loss, not to reverse existing damage.
Correct Answer is B
Explanation
A. An assistive personnel can evaluate a client's response to medication: Assistive personnel do not have the education or licensure to evaluate medication effects. They can perform delegated tasks such as vital signs or basic care, but assessment and evaluation of clinical responses remain within the RN’s scope of practice.
B. An RN can initiate the plan of care for a client on admission: Registered nurses are responsible for performing assessments, identifying nursing diagnoses, and developing an individualized plan of care upon admission. This is a core component of the RN’s legal scope of practice and requires professional judgment.
C. An RN can delegate blood administration to a licensed practical nurse: Blood administration is a high-risk procedure that generally cannot be delegated to an LPN in many states due to its complexity and potential for adverse reactions. The RN retains responsibility for administration and monitoring.
D. A licensed practical nurse can provide initial discharge instructions: Providing initial discharge instructions requires comprehensive assessment, education, and evaluation, which are within the RN’s scope of practice. LPNs may reinforce education but cannot independently provide initial instructions.
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