Nokea
A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?
- A. Serum potassium: 3.5 mEq/L, serum sodium: 142 mEq/L
- B. Serum potassium: 4.5 mEq/L, serum sodium: 140 mEq/L
- C. Serum potassium: 5.0 mEq/L, serum sodium: 138 mEq/L
- D. Serum potassium: 3.0 mEq/L, serum sodium: 149 mEq/L
Correct Answer: A
Rationale: Normal ranges expected unless significant imbalance occurs.
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A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement?
- A. Orient the client to their surroundings.
- B. Close the client's room door.
- C. Escort the client back to the room.
- D. Raise the four side rails on the bed.
- E. Secure a bed alarm on the mattress.
Correct Answer: A,C,E
Rationale: Orientation, escort, and alarm ensure safety.
History and Physical
2/15/2021
The patient is a 36-year-old female who is in the clinic today for insomnia. She reports that she started having trouble sleeping over a year ago after her father’s death. She has no medical problems and has never had surgery. She takes an oral contraceptive and a multivitamin daily. She does not smoke but drinks one to two glasses of wine every evening.
Nurse’s Notes
2/15/2021
Vital Signs:
• Temperature: 97°F (36.1°C) orally
• Heart rate: 59 beats/minute
• Respiratory rate: 16 breaths/minute
• Blood pressure: 116/72 mm Hg
Educated the patient on sleep hygiene techniques, such as avoiding exercise and caffeine right before bed.
3/2/2021
The patient is in the clinic following up after her sleep study, which showed no signs of sleep apnea. The patient continues to have poor sleep even with eliminating caffeine and doing a relaxing activity before bed, such as yoga. The patient will keep a sleep journal to document her sleep for the next 2 weeks.
3/16/2021
The patient completed a 2-week sleep journal. The patient falls asleep 1 to 2 hours after going to bed and wakes up 2 to 3 times per night. She does not have to use the restroom during the night. She experiences daytime drowsiness and headaches nowadays.
Orders
2/15/2021
Sleep study for 1 night.
What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.
- A. Exercise in the evening
- B. Watch television in bed to fall asleep.
- C. Take an analgesic before bed.
- D. Avoid alcohol in the evening.
- E. Try to go to bed and awaken at the same time every day.
- F. Avoid naps.
- G. Eat a heavy meal before bed.
Correct Answer: D,E,F
Rationale: Choice A reason:
Exercising in the evening can actually be counterproductive for some people when it comes to sleep. While regular exercise is beneficial for overall health and can contribute to better sleep, doing it too close to bedtime can stimulate the body, making it harder to relax and fall asleep.
Choice B reason:
Watching television in bed is generally not recommended as part of good sleep hygiene. The light from the screen can interfere with the body's production of melatonin, the hormone that signals it's time to sleep, and engaging content can keep the brain alert rather than allowing it to wind down.
Choice C reason:
Taking an analgesic before bed is not a general recommendation for better sleep unless pain is a specific issue that is preventing sleep. It's important to address the root cause of insomnia rather than masking symptoms with medication.
Choice D reason:
Avoiding alcohol in the evening is a good practice for better sleep. Alcohol can disrupt the sleep cycle and lead to fragmented sleep, even though it may initially seem to help with falling asleep.
Choice E reason:
Going to bed and waking up at the same time every day helps to regulate the body's internal clock, or circadian rhythm, which can improve sleep quality. Consistency is key for this practice to be effective.
Choice F reason:
Avoiding naps, especially in the late afternoon or evening, can help ensure that you are sufficiently tired at bedtime. Napping can interfere with nighttime sleep if done too late in the day or for too long.
Choice G reason:
Eating a heavy meal before bed can lead to discomfort and indigestion, which can make it harder to fall asleep. It's best to have a light snack if needed and avoid large meals close to bedtime.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Complete the intermittent suction of the nasopharynx.
- B. Apply an oxygen mask over the client's nose and mouth.
- C. Reposition the pulse oximeter clip to obtain a new reading.
- D. Stop suctioning until the pulse oximeter reading is above 95%.
Correct Answer: A
Rationale: Stable saturation allows safe continuation of suctioning.
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?
- A. Record the client's pulse rate and rhythm.
- B. Assist the client to stand at the bedside.
- C. Apply the blood pressure cuff securely.
- D. Position the client supine for a few minutes.
Correct Answer: D
Rationale: Supine position provides baseline for orthostatic assessment.
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Explain that since the medication is a controlled substance, it must be taken.
- B. Credit the medication back and put it in the client's medication box.
- C. Keep the medication and see if the client will want to take it later.
- D. Have another nurse witness the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal prevents misuse of controlled substances.