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

Answer and Explanation

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.

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Correct Answer is A

Explanation

After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels.

This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.

Choice B, supporting the client when rising, is important but should be done after assessing how the client feels.

Choice C, offering a pair of non-skid socks, may be helpful for safety but is not the most important action in this situation.

Choice D, placing the chair by the bed, should be done before moving the client to a sitting position.

A. Placing a client in restraints without having a healthcare provider's order. B. Administering the medication to a client behind a closed curtain. C. Enlisting security personnel to assist with restraining the client. D. Informing a client that the medication being administered is a sedative.

Correct Answer is A

Explanation

Placing a client in restraints without having a healthcare provider’s order.

It is inappropriate for a nurse to place a client in restraints without having a healthcare provider’s order.

Choice B is not the answer because administering the medication to a client behind a closed curtain is not necessarily inappropriate.

Choice C is not the answer because enlisting security personnel to assist with restraining the client may be necessary in some situations.

Choice D is not the answer because informing a client that the medication being administered is a sedative is not necessarily inappropriate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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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?