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 A
Explanation
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Correct Answer is A
Explanation
Reminiscing about the spouse with significant others. This is an important need for a widowed client during the grieving period following the death of the client’s spouse because it helps them process their loss, express their emotions, and honor their memories. Reminiscing can also provide comfort, support, and meaning to the bereaved.
Choice B. Self-indulgence in order to fill the emptiness left by the spouse’s death is wrong because it can be unhealthy, addictive, or harmful to the client’s well-being. Self-indulgence may also prevent the client from coping with their grief in a constructive way.
Choice C. Reassurance that the client did all that could be expected for their spouse is wrong because it may imply that the client is responsible for their spouse’s death or that they could have prevented it.
This may increase the client’s guilt, regret, or self-blame. Reassurance should focus on the client’s strengths, resilience, and coping skills.
Choice D. Engagement in activities that will take the client’s mind off the loss of the spouse is wrong because it may suggest that the client should avoid or deny their grief.
This may interfere with the healing process and lead to unresolved or complicated grief. Engagement in activities should be balanced with time for reflection, mourning, and self-care.
Normal ranges for grief vary depending on the individual, the relationship, and the circumstances of the death. However, some general guidelines are that grief can last from a few months to several years and that it may involve physical and emotional symptoms such as trouble sleeping, loss of appetite, difficulty concentrating, crying, sadness, anger,
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today