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. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.

B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.

C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.

A. "I should keep my baby rear-facing in the car seat until she is 2 years old." B. "I should position the car seat's retainer clip at the level of my baby's belly button." C. "I should enable the airbag when my baby is in the front seat of the car." D. "I should place my baby in the car seat at a 90-degree angle."

Correct Answer is A

Explanation

A. "I should keep my baby rear-facing in the car seat until she is 2 years old.": This is correct. The American Academy of Pediatrics recommends that infants and toddlers remain in a rear-facing car seat until they are at least 2 years old or until they reach the height and weight limits specified by the car seat manufacturer. Rear-facing provides the best protection for the baby's head, neck, and spine in the event of an accident.

B. "I should position the car seat's retainer clip at the level of my baby's belly button.": This is incorrect. The retainer clip should be positioned at armpit level, not at the belly button. This ensures the harness fits snugly and securely around the baby.

C. "I should enable the airbag when my baby is in the front seat of the car.": This is incorrect. Airbags should never be enabled when a baby is sitting in the front seat, as they can cause injury in the event of a collision. The baby should always be seated in the back seat of the car, as it is the safest location.

D. "I should place my baby in the car seat at a 90-degree angle.": This is incorrect. The car seat should be reclined at an angle of approximately 45 degrees to ensure the baby’s head does not fall forward, which could compromise breathing. A 90-degree angle is too upright and may be unsafe for a newborn.

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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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Correct Answer is A

Explanation

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Correct Answer is A

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