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A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

A.

Apply the client’s positive airway pressure device.

B.

Lift and lock the side rails in place.

C.

Remove dentures or other oral appliances.

D.

Elevate the head of the bed to a 45-degree angle.

Answer and Explanation

The Correct Answer is C

Choice A rationale

 

Elevating the head of the bed to a 45-degree angle can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. However, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.

 

Choice B rationale

 

Lifting and locking the side rails in place ensures the safety of the client but does not directly address the client’s OSA or the potential respiratory depression associated with opioid analgesic administration.

 

Choice C rationale

 

Applying the client’s positive airway pressure device is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.

 

Choice D rationale

 

Removing dentures or other oral appliances may be necessary for client comfort and safety, but it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.
 


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Positioning the head with the chin tilted slightly downward is an appropriate action when feeding a client with a CVA. This position helps prevent aspiration by closing the airway and directing food away from the trachea.

Choice B rationale

Allowing 30 minutes of rest before feeding is an appropriate action. Resting before feeding can help improve digestion and reduce the risk of aspiration by ensuring the client is alert and responsive during feeding.

Choice C rationale

Placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA. This technique helps the client manage food more effectively and reduces the risk of aspiration.

Choice D rationale

Raising the head of the bed to 60 degrees is not sufficient to prevent aspiration. The head of the bed should be elevated 45 to 90 degrees to ensure proper positioning and reduce the risk of aspiration. Therefore, if the UAP raises the head of the bed to only 60 degrees, it indicates the need for additional teaching.

Correct Answer is D

Explanation

Choice A rationale

Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.

Choice B rationale

Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.

Choice C rationale

Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.

Choice D rationale

Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

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