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
To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.
Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.
Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.
Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.
Correct Answer is C
Explanation
Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process 1.
Therefore, reducing the stimuli in the area can help the client’s brain to better process the information being taught.
Choice A is not the answer because demonstrating the skill speaking slowly and using simple terms does not address the issue of sensory overload 1.
Choice B is not the answer because reassuring the client that the skill is not difficult to learn does not address the issue of sensory overload 1.
Choice D is not the answer because providing step-by-step written instruction does not address the issue of sensory overload 1.
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