Nokea
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Drink a glass of milk before bedtime.
- C. Take a long walk before bedtime.
- D. Watch television in bed.
Correct Answer: B
Rationale: Milk contains tryptophan, which promotes sleep.
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A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has had varicella
- C. A client who is HIV-positive
- D. A client who has tuberculosis
Correct Answer: B
Rationale: A client with prior varicella is immune to herpes zoster, reducing transmission risk.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To an insurance agency in regard to a life insurance policy
- B. To a family member when the client is not available
- C. To a medical interpreter service on behalf of a client
- D. To an employer for a pre-employment screening
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed to facilitate care, adhering to HIPAA exceptions.
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Administering vaginal cream to a client who has a vaginal infection
- B. Providing postmortem care for a client who has just died
- C. Suctioning a tracheostomy for a client who has a recent head injury
- D. Changing a peripheral IV dressing for a client who is postoperative
Correct Answer: B
Rationale: Postmortem care is within the AP's scope; medication administration and invasive procedures are not.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. I can name my sibling as my designee in my durable power of attorney for health care.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: B
Rationale: Naming a designee is a key component of a durable power of attorney.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Unlock and remove the inner cannula.
- B. Scrub the inside and outside of the inner cannula with a small brush
- C. Wipe the inside of the inner cannula with a folded pipe cleaner.
- D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: A, D, B, C, E
Rationale: Sequence ensures sterile preparation and cleaning: remove cannula, prepare solution, scrub, wipe, cleanse stoma.