Which client is at greatest risk for development of obstructive sleep apnea?
a. Woman who is 8 months pregnant
b. Middle-aged man with gastroesophageal reflux disease
c. Middle-aged woman who is 50 pounds overweight
d. Older man with type 2 diabetes and a his-tory of sinus infections
C
The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.
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A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.
A nurse is about to administer a parenteral benzodiazepine to a female patient in the hospital before the performance of a procedure. What is the priority nursing action before administration of the drug?
A) Make sure that the side rails are up and the bed is in the lowest position. B) Close the blinds and ensure appropriate room temperature for the patient. C) Help the patient out of bed to the bathroom and encourage her to void. D) Ask all visitors to leave the room and remain in the waiting area.
A client scheduled to have blood drawn for a serum alpha1-antitrypsin level asks the nurse whether any special preparation is necessary. Since the client has a history of hyperlipidemia, the nurse should explain:
1. "A fasting specimen will be necessary." 2. "Any lipid-lowering medications should be held the day of the test." 3. "No special preparation is needed." 4. "A low-fat diet should be eaten for 24 hours prior to the test."
The client receives cyclophosphamide (Cytoxan) as treatment for cancer and experiences oral irritation as an adverse effect. What does the best plan of the nurse include to promote oral comfort?
1. Ice fluids before drinking. 2. Teach good oral hygiene, including rinsing the mouth with plain water after eating. 3. Teach the client to drink tea to keep tissues moist. 4. Teach the client to use a firm toothbrush for brushing teeth.