Nokea
A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1°F at 4 a.m. The nurse determines that this is most likely due to:
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm. The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature. While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the sleep period shifts, temperature fluctuations also shift to match the new sleep patterns.
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The nurse explains to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach?
- A. a high-protein meal
- B. a high-fat meal
- C. a large meal regardless of nutrient content
- D. a high-carbohydrate meal
Correct Answer: D
Rationale: Meals that are high in carbohydrates promote rapid gastric emptying. The other options are associated with decreased emptying time.
Using the FLACC pain scale, how should the LPN document pain for a non-verbal client with these findings: 1.Face-occasional grimacing 2.Legs-relaxed 3.Activity-Squirming 4.Cry-moans and whimpers 5.Consolability-distractible
- A. 5
- B. 4
- C. 3
- D. 8
Correct Answer: B
Rationale: The points add up like this: Face-1 Legs-0 Activity-1 Cry-1 Consolability-1 Total pain score-4
A client is to have an enema to reduce flatus. The enema tube should be inserted:
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct Answer: A
Rationale: Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel.
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and Bandaids™
Correct Answer: B
Rationale: Repositioning is the most effective way to prevent skin breakdown.