Nokea
A nurse assesses a client who reports waking up, feeling very tired, even after 4 hours of good sleep. Which action should the nurse take first?
- A. Assess for sleep apnea.
- B. Refer to a sleep specialist.
- C. Review the client's medication list.
- D. Encourage increased sleep duration.
Correct Answer: A
Rationale: The client's symptoms suggest possible sleep apnea, which can cause fatigue despite adequate sleep duration. Assessing for sleep apnea is the priority to identify the underlying cause and guide further management.
You may also like to solve these questions
A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
- A. Facial pain
- B. Vital signs
- C. Bone displacement
- D. Airway patency
Correct Answer: D
Rationale: A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.
A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, 'How will this medication help me?' How should the nurse respond?
- A. This medication will treat your sleep apnea.
- B. This sedative will help you to sleep at night.
- C. This medication will treat your daytime restlessness.
- D. This analgesic will increase comfort while you sleep.
Correct Answer: C
Rationale: Modafinil is used to promote wakefulness in clients with narcolepsy or daytime sleepiness related to sleep apnea, addressing excessive daytime restlessness.
A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?
- A. Initiate Standard Precautions.
- B. Apply direct pressure.
- C. Sit the client upright.
- D. Loosely pack the nose with gauze.
Correct Answer: A
Rationale: The nurse should implement Standard Precautions and don gloves prior to completing the other actions to ensure safety and infection control.
A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)
- A. A 32-year-old who had a radical neck dissection 6 hours ago.
- B. A 65-year-old who had a biopsy 2 days ago.
- C. A 55-year-old who needs discharge teaching after a laryngectomy.
- D. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer.
- E. An 80-year-old with esophageal cancer who is awaiting gastric tube placement.
Correct Answer: B,E
Rationale: The RN can delegate stable clients, such as the client 2 days post-biopsy and the client awaiting gastric tube placement, to the LPN. Clients who are 6 hours post-surgery or require teaching cannot be delegated.
A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture.
- A. You will need to cut the wires if you start vomiting.
- B. Eat soft or liquid meals each day while recovering.
- C. Irrigate your mouth every 2 hours to prevent infection.
- D. Sleep in a semi-Fowler's position after the surgery.
- E. Gargle with mouthwash that contains Benadryl once a day.
Correct Answer: A,B,C,D
Rationale: The client should be taught to cut wires in case of vomiting to prevent aspiration, eat soft or liquid meals, irrigate the mouth to prevent infection, and sleep in a semi-Fowler's position to reduce aspiration risk. Benadryl mouthwash is not indicated for this condition.