The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).
Which interaction is most important for the nurse to implement before leaving the client?
Elevate the head of the bed to a 45-degree angle
Apply the client's positive airway pressure device
Lift and lock the side rails in place
Remove dentures or other oral appliances
The Correct Answer is B
The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep 1.
Choice A is not the answer because elevating the head of the bed to a 45-degree angle may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.
Choice C is not the answer because lifting and locking the side rails in place is a safety measure but does not directly address the client’s OSA 1.
Choice D is not the answer because removing dentures or other oral appliances may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.
Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.
In fact, it is recommended that you brush your teeth at least once every four hours1.
Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.
Choice D is incorrect because positioning the unconscious client upright is not the best method.
Instead, they should be placed in a side-lying position to prevent aspiration1.
Correct Answer is D
Explanation
The correct answer is choice D.
When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops.
This position allows the medication to flow into the ear canal and reach the site of infection.
Choice A is not correct because it is not necessary to swab and shake the bottle before administering the drops.
Choice B is not correct because tilting the head upright would cause the medication to flow out of the ear canal instead of reaching the site of infection.
Choice C is not correct because lowering the edge of the dropper into the canal of the ear could cause injury or discomfort to the patient.
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