A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper CPAP use?

There is one finger width between the strap on the mask and the client's face.

The therapeutic dose of albuterol is being inhaled.

The mask fits loosely so air can escape from underneath.

The mask is secured over the client's mouth and the client's nose is uncovered.

Answer and Explanation

The Correct Answer is A

A. There is one finger width between the strap on the mask and the client's face is correct. A properly fitted CPAP mask should have a snug fit, with a space of about one finger width between the strap and the face to ensure adequate seal and comfort. A mask that is too tight can cause discomfort, while a loose mask may not provide the necessary pressure to treat sleep apnea.

B. The therapeutic dose of albuterol is being inhaled is incorrect. Albuterol is used for bronchodilation in conditions like asthma, but it is not related to CPAP use. CPAP is designed to provide positive pressure to keep the airways open, not to treat asthma or other respiratory issues directly.

C. The mask fits loosely so air can escape from underneath is incorrect. A loose fit would lead to air leakage, reducing the effectiveness of the CPAP therapy. The mask should fit securely to ensure the proper amount of air pressure is delivered during sleep.

D. The mask is secured over the client's mouth and the client's nose is uncovered is incorrect. For effective CPAP therapy, the mask should cover both the nose and mouth, unless the client specifically uses a nasal CPAP mask designed to deliver pressure only through the nose.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.

B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.

C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.

D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.

A. Hold the irrigation solution bottle 5 cm (2 in) above the sterile container. B. Open the outer wrapper of the sterile package toward her body. C. Place the irrigation solution bottle cap on the sterile field. D. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

Correct Answer is D

Explanation

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

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A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper CPAP use?

Nursing Test Bank

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