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    HESI Exit II Proctored ExamQuestion 32
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    HESI Exit II Proctored Exam

    A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

    Explanation & Rationale

    Choice B reason: Elevating the head of the bed to a 45-degree angle is not a sufficient intervention for the nurse to implement before leaving the client. Elevating the head of the bed can help reduce snoring and improve breathing by preventing the tongue and soft palate from falling back and obstructing the airway. However, it may not be enough to prevent apnea episodes in clients with obstructive sleep apnea, especially if they have other risk factors such as obesity, enlarged tonsils, or nasal congestion. The nurse should also use other interventions such as a positive airway pressure device, weight loss, or surgery. Choice C reason: Removing dentures or other oral appliances is not a relevant intervention for the nurse to implement before leaving the client. Dentures or other oral appliances are devices that replace missing teeth or improve dental alignment. They may help improve speech, chewing, and appearance, but they do not have a direct impact on obstructive sleep apnea. The nurse should instruct the client to remove dentures or other oral appliances before going to bed to prevent discomfort, infection, or damage. Choice D reason: Lifting and locking the side rails in place is not a necessary intervention for the nurse to implement before leaving the client. Side rails are bars that attach to the sides of the bed frame to prevent falls or injuries. They may provide safety and security for some clients, but they may also pose risks such as entrapment, strangulation, or agitation. The nurse should assess the need for side rails on an individual basis and consider alternative measures such as bed alarms, low beds, or floor mats.

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