The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. 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.

Remove dentures or other oral appliance.

Lift and lock the side rails in place.

Apply the client's positive airway pressure device.

Answer and Explanation

The Correct Answer is D

A. Elevate the head of the bed to a 45-degree angle may be helpful for some clients with OSA, but the most crucial intervention for a client with OSA is ensuring the proper use of the positive airway pressure (PAP) device.

B. Remove dentures or other oral appliance is not a priority for clients with OSA unless specifically contraindicated by the healthcare provider. The main concern is ensuring the PAP device is in place to prevent airway obstruction.

C. Lift and lock the side rails in place is a general safety measure, but it is not as critical as ensuring the client has their PAP device applied.

D. Apply the client's positive airway pressure device is the most important intervention. The PAP device (e.g., CPAP or BiPAP) helps keep the airway open during sleep, preventing apneas and improving oxygenation. Ensuring the client has this device in place is the most essential action before leaving the client alone.

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Correct Answer is B

Explanation

A. Advise the UAP to hold the thermometer securely in place for a full three minutes is incorrect because tympanic thermometers provide quick readings, typically within a few seconds, and do not require prolonged placement.

B. Use positive reinforcement to affirm that the procedure is being performed correctly is the correct action. For adult clients, the auricle should be pulled up and back to straighten the ear canal for accurate tympanic temperature measurement. Positive reinforcement supports the UAP's learning and confidence.

C. Demonstrate the correct technique for pulling the client's auricle down and back is incorrect for adult clients. Pulling the auricle down and back is appropriate for children under 3 years old, not adults.

D. Remind the UAP to lubricate the thermometer before gently inserting in the ear is not appropriate. Tympanic thermometers do not require lubrication, as they are designed for non-invasive and quick use.

A. Apply sterile-strips. B. Obtain a wound culture. C. Apply a debriding agent. D. Remove every other suture.

Correct Answer is B

Explanation

A. Apply sterile-strips is not the most appropriate action. Steri-strips are typically used for approximating wound edges or supporting sutures, but they are not the first intervention when there is concern about infection or unusual exudate.

B. Obtain a wound culture is the correct action. A thick tan exudate may indicate infection or an abnormal healing process. The nurse should obtain a wound culture to identify the presence of infection and guide appropriate treatment.

C. Apply a debriding agent is premature without first assessing the wound for infection. Debridement is typically used to remove necrotic tissue, but the priority is to determine whether an infection is present before proceeding with debridement.

D. Remove every other suture is not indicated. Sutures should not be removed unless instructed by the healthcare provider, and there is no indication that sutures need to be removed at this time. The focus should be on assessing the wound for infection first.

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The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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