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

To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.

This will help the nurse to understand the characteristics of the pain and how it is affecting the client.

Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.

Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.

Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.

A. Review the chart for number of voids over the last 24 hours. B. Evaluate the client for urinary incontinence. C. Scan the client's bladder after voiding. D. Palpate the suprapubic region for distention.

Correct Answer is C

Explanation

This will help determine if there is any residual urine left in the bladder after voiding.

Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.

Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.

Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.

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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

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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?