Which finding in a client diagnosed with obstructive sleep apnea (OSA) would require a nurse to take immediate action?
Client difficult to arouse.
Blood pressure 142/92 mmHg.
Apneic periods lasting more than 10 seconds.
Oxygen desaturation to 90% when asleep.
The Correct Answer is A
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A heart murmur is a priority assessment for a toddler who is diagnosed with fetal alcohol syndrome because it may indicate a congenital heart defect, which can affect the child’s growth, development and oxygenation. According to the health search results, fetal alcohol syndrome can cause heart and kidney problems, among other complications.
Choice A is wrong because small head size is a common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has microcephaly, which is associated with intellectual and learning disabilities.
Choice B is wrong because poor coordination is another common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has problems with motor skills and balance.
Choice C is wrong because speech and language delays are also common features of fetal alcohol syndrome, but they are not a priority assessment. They indicate that the child has problems with communication and social skills.
Correct Answer is B
Explanation
The nurse should make the statement “The client has hypoxemia after 10 minutes on a rebreather mask.” first. This is because SBAR (Situation- Background-Assessment-Recommendation) is a communication tool that helps provide essential, concise information, usually during crucial situations. The first component of SBAR is Situation, which is a concise statement of the problem.
The nurse should state the most urgent and relevant problem first, which is the client’s hypoxemia.
Choice A is wrong because it is not a clear statement of the situation.
It is vague and does not provide specific information about the client’s condition or vital signs.
It also expresses the nurse’s feeling rather than an objective assessment.
Choice C is wrong because it is part of the Assessment component of SBAR, not the Situation.
It provides numerical data about the client’s blood gas analysis, but it does not state the problem or the reason for calling the healthcare provider.
Choice D is wrong because it is part of the Background component of SBAR, not the Situation.
It provides pertinent and brief information related to the situation, such as the client’s medical history and diagnosis, but it does not state the current problem or concern.
Normal ranges for blood gas analysis are:
- PaO2: 80-100 mmHg
- PaCO2: 35-45 mmHg
- HCO3: 22-26 mEq/L
Hypoxemia is defined as a low level of oxygen in the blood, usually below 60 mmHg.
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