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?
Apply the client’s positive airway pressure device.
Lift and lock the side rails in place.
Remove dentures or other oral appliances.
Elevate the head of the bed to a 45-degree angle.
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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Correct Answer is A
Explanation
Choice A rationale
The SBAR (Situation, Background, Assessment, Recommendation) format is specifically designed for critical communication, particularly when reporting a change in a client’s condition to the healthcare provider. This structured communication tool ensures that essential information is conveyed clearly and concisely, reducing the risk of miscommunication and enhancing patient safety.
Choice B rationale
Completing discharge teaching to a client and family members typically involves providing comprehensive instructions and education, which may not fit the concise and focused nature of the SBAR format. Discharge teaching requires a more detailed and interactive approach to ensure understanding and compliance.
Choice C rationale
Obtaining clarification from a client’s healthcare power-of-attorney involves a more conversational and detailed exchange of information, which may not align with the structured and concise nature of the SBAR format. This interaction often requires a thorough discussion to ensure all aspects are understood.
Choice D rationale
Offering therapeutic support and comfort to a grieving family is a sensitive and empathetic interaction that requires a compassionate and patient-centered approach. The SBAR format is not suitable for this type of communication, as it is designed for conveying critical information quickly and efficiently.
Correct Answer is A
Explanation
Choice A rationale
Ensuring the bevel of the needle is pointing up is crucial for intradermal injections as it allows the medication to be deposited just below the epidermis, forming a small bleb or wheal.
Choice B rationale
The upper arm is not the preferred site for intradermal injections. The inner forearm and upper back are more commonly used as they allow for better visualization of the reaction.
Choice C rationale
Holding the syringe perpendicular to the skin is incorrect for intradermal injections. The correct angle is 5 to 15 degrees to ensure the medication is deposited in the dermis.
Choice D rationale
Massaging the site gently after injection is not recommended for intradermal injections as it can disperse the medication and affect the test results.