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A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?
- A. Starting an exercise program
- B. Keeping a sleep diary
- C. Practicing relaxation techniques before bed
- D. Using sleep-inducing medications at night
Correct Answer: C
Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.
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A client with a diagnosis of osteoporosis is prescribed alendronate (Fosamax). What is the most important instruction the nurse should provide?
- A. Take the medication in the morning on an empty stomach.
- B. Take the medication at bedtime.
- C. Remain upright for at least 30 minutes after taking the medication.
- D. Take the medication with a full glass of water.
Correct Answer: D
Rationale: The most important instruction the nurse should provide to a client prescribed alendronate (Fosamax) for osteoporosis is to take the medication with a full glass of water. This is crucial to help prevent esophageal irritation. Option A is correct as alendronate should be taken in the morning on an empty stomach. Option C is incorrect because the client should remain upright for at least 30 minutes after taking the medication, not lie down. Option B is incorrect and a duplicate of Option A.
A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. What is the primary purpose of this medication?
- A. To lower blood pressure
- B. To improve appetite
- C. To increase red blood cell production
- D. To reduce fluid retention
Correct Answer: C
Rationale: The correct answer is C: 'To increase red blood cell production.' Erythropoietin stimulates the production of red blood cells to treat anemia associated with CKD. Choices A, B, and D are incorrect because erythropoietin therapy is primarily used to address anemia by increasing the production of red blood cells rather than lowering blood pressure, improving appetite, or reducing fluid retention.
The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?
- A. Apply an ice pack
- B. Document the findings and monitor
- C. Notify the surgeon
- D. Clean the wound with sterile saline
Correct Answer: C
Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.
The nurse is teaching a client with hypertension about lifestyle modifications. Which recommendation is most effective for lowering blood pressure?
- A. Increase intake of red meat
- B. Engage in regular physical activity
- C. Consume a high-sodium diet
- D. Limit fluid intake to 1 liter per day
Correct Answer: B
Rationale: Engaging in regular physical activity is a highly effective recommendation for lowering blood pressure and improving overall cardiovascular health. Regular exercise helps to strengthen the heart, improve blood circulation, and manage weight, all of which contribute to reducing blood pressure levels. Choices A, C, and D are incorrect. Increasing intake of red meat can lead to higher saturated fat consumption, which is detrimental to heart health. Consuming a high-sodium diet can exacerbate hypertension by increasing blood pressure. Limiting fluid intake to 1 liter per day may lead to dehydration and is not a recommended approach for managing hypertension.
The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?
- A. Ask the client why the bath was refused
- B. Ask family members to encourage the client to bathe
- C. Explain the importance of good hygiene to the client
- D. Reschedule the bath for the following day
Correct Answer: A
Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.