Today’s NCLEX-RN® question of the day focuses on the postoperative assessment of a client with obstructive sleep apnea. What should a nurse keep an eye on?
During the postoperative assessment of a client with a history of obstructive sleep apnea (OSA), which assessment finding should cause the nurse the most concern?
A. Irregular and noisy respirations
B. Disorientation and confusion
C. A report of dry mouth and sore throat
D. A pain report of 8 on a 0-10 scaleScroll down for the correct answer!
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The correct answer to today’s NCLEX-RN® Question is…
A. Irregular and noisy respirations
Rationale: A history of OSA is a risk factor for postoperative airway obstruction, and irregular, noisy respirations are a sign of impending obstruction. Postoperative pain can be managed, disorientation is common, dry mouth is a common side-effect of perioperative medications like atropine, and intubation often causes a sore throat.
Major takeaway
A history of OSA is a risk factor for postoperative airway obstruction, so the nurse should be alert for irregular, noisy respirations, which are a sign of impending obstruction.
Incorrect answer explanations
B. Disorientation and confusion
Rationale: Disorientation and confusion are common when awakening from anesthesia, though the nurse should continue to monitor mental status.
C. A report of dry mouth and sore throat
Rationale: A dry mouth is expected secondary to atropine administration and a sore throat is common after extubation.
D. A pain report of 8 on a 0-10 scale
Rationale: The report signals a high level of pain, but this can be managed by administering the prescribed pain medications.
Reference
Berman, A., Snyder, S. Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts, Process, and practice. Boston, MA: Pearson.
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