Nokea
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Turn off alarms on bedside monitoring equipment
- B. Avoid entering the client's room unless requested during the night.
- C. Conduct staff communications away from the client's room.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: C
Rationale: Conducting staff communications away from the client's room reduces noise and promotes a restful environment.
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A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Provide the client with snug-fitting nightwear.
- B. Keep the door to the client's room closed.
- C. Administer prescribed diuretics in the evening.
- D. Use overhead lighting when checking equipment.
Correct Answer: B
Rationale: A closed door minimizes disturbances, promoting sleep.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Apply lidocaine gel to the urethra.
- B. Twist the catheter gently.
- C. Inflate the catheter's balloon.
- D. Lower the penis to a 45° angle.
Correct Answer: B
Rationale: Gently twisting the catheter may navigate past resistance, often due to the prostatic urethra.
A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
- A. Rapid chewing
- B. Garbled voice
- C. Sneezing
- D. Increased hunger
Correct Answer: B
Rationale: A garbled or 'wet' voice indicates difficulty swallowing, a sign of dysphagia.
A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has an elevated hemoglobin level.
- B. The client is wearing nail polish.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: B
Rationale: Nail polish, especially dark colors, can block the pulse oximeter sensor, affecting accuracy.
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I'll use focused breathing to control my pain.
- B. I'll learn to notice the sensation of muscle tension.
- C. I think about my grandfather's farm to reduce pain.
- D. I listen to my favorite music to take my mind off the pain.
Correct Answer: C
Rationale: Guided imagery involves visualizing a calming scene like a farm to distract from pain.