Question

A client diagnosed with obstructive sleep apnea (OSA) is prescribed a continuous positive airway pressure (CPAP) machine and mask. The nurse understands which is a benefit of using CPAP? (Select all that apply.)

Answer 1

Correct Answers:

Improves quality of sleep.
Reduces daytime sleepiness.
Lowers risk of stroke.
Prevents hypertension.

Rationale :

🌿Improves quality of sleep CPAP prevents airway collapse, allowing continuous airflow throughout sleep.

🌿 Restores normal sleep cycles, especially REM sleep.

🌿 Reduces nighttime arousals, improving rest.

🌿 Clients report longer periods of deep sleep.

🌿 Enhances overall sleep efficiency.

🌿Reduces daytime sleepiness Treats the repeated oxygen drops caused by OSA.

🌿 Prevents nighttime micro-arousals responsible for fatigue.

🌿 Promotes stable sleep architecture, improving alertness.

🌿 Reduces the risk of accidents due to somnolence.

🌿 Improves cognitive function and mood.

🌿Lowers risk of stroke OSA increases cardiovascular strain, raising stroke risk.

🌿 CPAP improves oxygenation, relieving vascular stress.

🌿 Consistent nighttime ventilation reduces blood pressure spikes.

🌿 Helps maintain better cerebral perfusion.

🌿 Evidence links CPAP to reduced ischemic events.

🌿Prevents hypertension OSA causes sympathetic overactivation, elevating BP.

🌿 CPAP decreases nighttime vasoconstriction.

🌿 Improves overall hemodynamic stability. 🌿 Reduces episodes of nocturnal hypoxemia.

🌿 Long-term use correlates with improved blood pressure control.

Lowers serum cholesterol

🌿 CPAP does not directly affect cholesterol metabolism.

🌿 Cholesterol changes require diet, exercise, or medication.

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Answer 2

Correct Answers:

Administer a beta-blocker medication.
Transfer to radiology for a computed tomography (CT) scan of the head.
Obtain the client's international normalized ratio (INR).

Rationale :

💠Administer a beta-blocker Atrial fibrillation with rapid ventricular response (HR 120) needs rate control.

💠 Beta-blockers reduce myocardial oxygen demand.

💠 Prevents worsening of stroke perfusion.

💠 Stabilizes hemodynamics for safe imaging/treatment.

💠 Standard first-line approach.

💠CT scan of the head Must determine ischemic vs hemorrhagic stroke immediately.

💠 Warfarin increases bleed risk → CT is urgent.

💠 Treatment (tPA, antiplatelets) depends on imaging findings.

💠 Prevents unsafe medication administration.

💠 First step in all acute stroke evaluations.

💠Obtain INR Client takes warfarin, requiring assessment of coagulation.

💠 High INR increases risk of intracranial hemorrhage.

💠 Determines if aspirin or heparin is safe to give.

💠 Guides reversal decisions if bleed is present.

💠 Critical stroke safety measure.

Incorrect Options (2 points each)

Administer aspirin Unsafe until CT confirms no bleeding.

💠 Warfarin increases hemorrhage risk.

Start heparin infusion

💠 A-fib stroke requires heparin ONLY after ruling out brain bleed.

💠 Warfarin + heparin = dangerous combo if bleed present.

Prepare for emergency cardioversion

💠 Cardioversion risks embolizing clots in uncontrolled A-fib.

💠 NEVER performed emergently during acute stroke

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Answer 3

Correct Answers

Blank 1 Correct Option: Guillain Barré syndrome (GBS)
Blank 2 Correct Option: Discuss mechanical ventilation and Encourage active ROM
Blank 3 Correct Option: Muscle strength and Pulmonary function

Rationale :

🌟 Progressive ascending weakness with absent reflexes strongly indicates GBS.

🌟 History of recent gastroenteritis fits known immune trigger.

🌟 EMG shows slowed nerve conduction, confirming demyelination.

🌟 Monitoring respiratory effort is critical—GBS can cause respiratory failure.

🌟 Encouraging ROM prevents contractures and supports recovery.

ALS

🌟 ALS is slow-progressing, not acute.

🌟 Does NOT start abruptly with ascending weakness.

Bell palsy

🌟 Only affects facial nerve.

🌟 No ascending motor paralysis.

Peripheral neuropathy

🌟 Usually involves sensory loss, which is absent here.

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Answer 4

Correct Answers:

There is good blood flow in the ulnar artery.

Rationale :

✨ A positive Allen test means the hand flushes pink after releasing ulnar pressure.

✨ Indicates adequate collateral circulation via ulnar artery.

✨ Safe to perform radial artery puncture for ABG.

✨ Ensures that if radial artery is damaged, hand will still receive blood.

✨ Positive = normal finding.

Notify provider

✨ There is no emergency — this is a normal result.

Insufficient radial blood flow

✨ Negative test indicates poor ulnar flow, not radial issues.

Good femoral artery flow

✨ Allen test does not assess femoral artery.

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Answer 5

Correct Answers:

Alanine aminotransferase (ALT) of 2,600 U/L (43.42 mckat/L).

Rationale :

🌼 ALT is the most liver-specific enzyme for hepatocellular damage.

🌼 ALT 2,600 U/L indicates massive hepatocyte injury.

🌼 Viral hepatitis typically elevates ALT more than AST.

🌼 Extremely high levels signal risk for acute liver failure.

🌼 Must be reported immediately for urgent intervention.

AST 2,200 U/L

🌼 Elevated but less liver-specific than ALT.

🌼 Still concerning, but ALT is more critical.

Platelets 460,000

🌼 Elevated platelets do not indicate liver failure.

🌼 Not the priority.

Ammonia 55

🌼 Mildly elevated; concerning but not the highest urgency.

🌼 ALT signals more severe liver injury.

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Answer 6

Correct Answers:

Administer a parenteral corticosteroid medication

Rationale :

🌿 Severe nausea, vomiting, hypotension, and hyperpigmentation indicate an Addisonian crisis requiring immediate steroid replacement.

🌿 Parenteral corticosteroids (hydrocortisone IV) are lifesaving because they replace missing cortisol.

🌿 Low cortisol leads to vascular collapse, so rapid steroid administration restores blood pressure.

🌿 Steroids also correct electrolyte abnormalities, especially hyperkalemia and hyponatremia.

🌿 This intervention treats the ** underlying cause**, not just symptoms.

Administer an antiemetic

🌿 Does not treat the life-threatening cortisol deficiency.

🌿 Only manages symptoms.

Assess skin for a rash

🌿 Skin changes are expected in Addison disease and not priority.

🌿 Does not address shock.

Assess breathing pattern

🌿 Assessment is important but does not correct hypotension or crisis.

🌿 Steroids must be given first.

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Answer 7

Correct Answers:

The unit can be A or O negative and be transfused.

Rationale :

🔷 A negative clients can only receive Rh-negative blood.

🔷 Type A negative accepts A negative (same type) and O negative (universal donor).

🔷 Giving Rh-positive blood to Rh-negative clients causes hemolytic reactions.

🔷 Type O negative contains no A or B antigens, making it safest.

🔷 This follows standard ABO and Rh compatibility rules.

A positive can be used

🔷 Contains Rh-positive, unsafe for Rh-negative clients.

🔷 May trigger immune reaction.

B negative

🔷 Contains B antigens, incompatible with Type A.

🔷 Causes hemolysis.

AB negative

🔷 Contains A and B antigens.

🔷 Not compatible with Type A recipients.

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Answer 8

Correct Answers:

The client will have increased exercise tolerance.

Rationale :

💠 An EF of 22% indicates severe systolic heart failure.

💠 The primary treatment goal is improving cardiac output, which increases exercise tolerance.

💠 Increased tolerance means improved forward flow and better functional capacity.

💠 It is an objective measure of stabilized heart function.

💠 Evidence-based therapies (ACE inhibitors, beta-blockers, diuretics) focus on this goal.

Decreased nocturia

💠 Nocturia varies and is not the primary goal of HF management.

Decreased dyspnea at rest

💠 Dyspnea at rest indicates late-stage HF — improvement is ideal but not the primary goal.

No peripheral edema

💠 Complete elimination is unrealistic and not the top measurable goal.

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Answer 9

Correct Answers:

Hematuria.
Severe joint pain.
Tachycardia.
Dyspnea

Rationale :

🌟Hematuria Sickle cells block renal vessels causing renal ischemia → blood in urine.

🌟 Common during vaso-occlusive crisis.

🌟 Indicates vascular complications.

🌟 Shows end-organ involvement.

🌟 Must be monitored for acute kidney injury.

🌟Severe joint pain Hallmark of vaso-occlusive crisis due to blocked microvasculature.

🌟 Joints become hypoxic and painful.

🌟 Often requires opioid management.

🌟 This is the most frequent reported symptom.

🌟 Indicates widespread sickling.

🌟Tachycardia Anemia causes compensatory increased heart rate.

🌟 Helps maintain oxygen delivery.

🌟 Common physiologic response.

🌟 Can escalate into cardiac strain.

🌟 Expected during painful crises.

🌟Dyspnea Low hemoglobin causes poor oxygen transport → shortness of breath.

🌟 Chest involvement may suggest acute chest syndrome.

🌟 Hypoxia worsens sickling.

🌟 Dyspnea is a red-flag symptom.

🌟 Requires close monitoring.

Thrombocytopenia

🌟 SCD typically causes increased platelet activation, not low platelets.

🌟 Thrombocytopenia is not typical in vaso-occlusive crisis.

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Answer 10

Correct Answers:

Assist the client to void immediately before transport.

Rationale :

✨ Voiding before surgery prevents bladder distention during anesthesia.

✨ It is a safe, routine task appropriate for UAP.

✨ Requires no specialized nursing judgment.

✨ Enhances client comfort and reduces postoperative urinary issues.

✨ Frees the nurse to complete preoperative assessments.

Provide hand-off report

✨ Nursing-only task requiring clinical judgment.

✨ UAP cannot report patient condition.

Witness consent

✨ Only licensed nurses or providers may verify legal consent.

✨ Beyond UAP scope.

Teach breathing and coughing

✨ Teaching requires RN-level education and evaluation.

✨ Not delegated to UAP.

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QLexNursing

1 :
A client diagnosed with obstructive sleep apnea (OSA) is prescribed a continuous positive airway pressure (CPAP) machine and mask. The nurse understands which is a benefit of using CPAP? (Select all that apply.)

3 :
The nurse cares for an adult client in an emergency department (ED) who is reporting progressive muscle weakness.

Correct Answers

4 :
with chronic obstructive pulmonary disease (COPD). The technician tells the nurse the Allen test is positive before the ABG is done. Which interpretation by the nurse is correct?

5 :
The nurse reviews the laboratory results of a client diagnosed with viral hepatitis. Which increased laboratory result is most important for the nurse to report to the health care provider?

6 :
The nurse assesses an adult client with a history of Addison disease presenting with severe nausea, vomiting, and abdominal pain. The client's blood pressure is 80/50 mmHg and the nurse notes hyperpigmentation of the skin. Based on the client's presentation, which is the priority intervention?

7 :
The nurse prepares to transfuse a unit of packed red blood cells to a client who is blood type A negative. The nurse understands which is correct about the unit to be infused?

8 :
The nurse cares for a client with heart failure who has an ejection fraction of 22%. The nurse identifies which desired treatment outcome as the most appropriate for this client?

9 :
A young adult client diagnosed with sickle cell disease (SCD) arrives at the clinic reporting increased pain and anemia. Vaso-occlusive crisis is diagnosed. The nurse understands which symptom is expected? (Select all that apply.)

10 :
The nurse provides care to a client scheduled for surgery. Which action does the nurse delegate to the unlicensed assistive personnel (UAP) to prepare the client for the procedure?

QLexNursing

1 : A client diagnosed with obstructive sleep apnea (OSA) is prescribed a continuous positive airway pressure (CPAP) machine and mask. The nurse understands which is a benefit of using CPAP? (Select all that apply.)

3 : The nurse cares for an adult client in an emergency department (ED) who is reporting progressive muscle weakness.

Correct Answers

4 : with chronic obstructive pulmonary disease (COPD). The technician tells the nurse the Allen test is positive before the ABG is done. Which interpretation by the nurse is correct?

5 : The nurse reviews the laboratory results of a client diagnosed with viral hepatitis. Which increased laboratory result is most important for the nurse to report to the health care provider?

6 : The nurse assesses an adult client with a history of Addison disease presenting with severe nausea, vomiting, and abdominal pain. The client's blood pressure is 80/50 mmHg and the nurse notes hyperpigmentation of the skin. Based on the client's presentation, which is the priority intervention?

7 : The nurse prepares to transfuse a unit of packed red blood cells to a client who is blood type A negative. The nurse understands which is correct about the unit to be infused?

8 : The nurse cares for a client with heart failure who has an ejection fraction of 22%. The nurse identifies which desired treatment outcome as the most appropriate for this client?

9 : A young adult client diagnosed with sickle cell disease (SCD) arrives at the clinic reporting increased pain and anemia. Vaso-occlusive crisis is diagnosed. The nurse understands which symptom is expected? (Select all that apply.)

10 : The nurse provides care to a client scheduled for surgery. Which action does the nurse delegate to the unlicensed assistive personnel (UAP) to prepare the client for the procedure?

1 :
A client diagnosed with obstructive sleep apnea (OSA) is prescribed a continuous positive airway pressure (CPAP) machine and mask. The nurse understands which is a benefit of using CPAP? (Select all that apply.)

3 :
The nurse cares for an adult client in an emergency department (ED) who is reporting progressive muscle weakness.

4 :
with chronic obstructive pulmonary disease (COPD). The technician tells the nurse the Allen test is positive before the ABG is done. Which interpretation by the nurse is correct?

5 :
The nurse reviews the laboratory results of a client diagnosed with viral hepatitis. Which increased laboratory result is most important for the nurse to report to the health care provider?

6 :
The nurse assesses an adult client with a history of Addison disease presenting with severe nausea, vomiting, and abdominal pain. The client's blood pressure is 80/50 mmHg and the nurse notes hyperpigmentation of the skin. Based on the client's presentation, which is the priority intervention?

7 :
The nurse prepares to transfuse a unit of packed red blood cells to a client who is blood type A negative. The nurse understands which is correct about the unit to be infused?

8 :
The nurse cares for a client with heart failure who has an ejection fraction of 22%. The nurse identifies which desired treatment outcome as the most appropriate for this client?

9 :
A young adult client diagnosed with sickle cell disease (SCD) arrives at the clinic reporting increased pain and anemia. Vaso-occlusive crisis is diagnosed. The nurse understands which symptom is expected? (Select all that apply.)

10 :
The nurse provides care to a client scheduled for surgery. Which action does the nurse delegate to the unlicensed assistive personnel (UAP) to prepare the client for the procedure?