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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Correct Answer is A

Explanation

A. An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.

B. An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.

C. A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.

D. Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.

A. A client who has a sodium level of 140 mEq/L after one episode of diarrhea. B. A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf. C. A client who has atrial fibrillation and an INR of 4. D. A client who reports chest pain after ambulating.

Correct Answer is A

Explanation

A. "A client who has a sodium level of 140 mEq/L after one episode of diarrhea." This is the correct choice. A sodium level of 140 mEq/L is within the normal range, and the client has had only one episode of diarrhea, suggesting that they are stable and could be safely discharged.

B. "A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf." This is a concern. The warm, red area on the calf could indicate the presence of a deep vein thrombosis (DVT) or infection, both of which require further evaluation and management.

C. "A client who has atrial fibrillation and an INR of 4." This is concerning. An INR of 4 indicates an increased risk of bleeding, which requires closer monitoring and potentially adjusting the anticoagulation therapy before discharge.

D. "A client who reports chest pain after ambulating." This is an urgent issue that needs immediate attention. Chest pain could indicate a serious cardiac event, such as a myocardial infarction, and the client should not be discharged until further evaluation is performed.

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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?

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