Nokea
The nurse is interviewing an older adult who reports a disturbed sleep pattern. The client states that he lies in bed tossing and turning and cannot fall asleep. The nurse should recommend that the client
- A. Stay in bed until he falls asleep but change positions more frequently.
- B. Take more naps earlier in the day that do not exceed one hour.
- C. Eat a meal high in carbohydrates to promote sleep.
- D. Reduce your time in bed if unable to fall asleep after 20 minutes.
Correct Answer: D
Rationale: Leaving bed after 20 minutes prevents associating bed with sleeplessness, a sleep hygiene principle. Staying in bed, napping, or high-carb meals disrupt sleep patterns.
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The nurse has attended a continuing education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed
- A. wearing gloves when obtaining vital signs.
- B. cohorting two clients with influenza in the same room.
- C. wearing a surgical mask when caring for a client with suspected rabies.
- D. initiating droplet precautions for a client with viral pneumonia.
Correct Answer: B,D
Rationale: Cohorting influenza clients and initiating droplet precautions for viral pneumonia align with infection control guidelines. Gloves for vital signs and a mask for rabies are not standard.
The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first?
- A. Obtain a fire extinguisher
- B. Close the bathroom door
- C. Remove the client from the room
- D. Activate the fire alarm
Correct Answer: C
Rationale: Removing the client from the room prioritizes safety in a potential fire hazard. Other actions follow after ensuring client safety.
The nurse is assessing a client's peripheral vascular access device. The assessment shows that the site is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which of the following complications is the client experiencing?
- A. Occlusion
- B. Infiltration
- C. Phlebitis
- D. Air embolism
Correct Answer: C
Rationale: Redness, warmth, pain, and edema indicate phlebitis, vein inflammation. Occlusion blocks flow, infiltration involves fluid leakage, and air embolism is unrelated.
The nurse enters a client's room who is found on the ground. The nurse should perform which initial action?
- A. Assess the client's level of consciousness
- B. Examine the client for injuries
- C. Call the rapid response team (RRT)
- D. Palpate the client's carotid pulse
Correct Answer: A
Rationale: Assessing the level of consciousness is the initial action to determine the client's neurological status and guide further interventions after a fall.
The nurse is teaching a client with hypothyroidism. The nurse should recommend that the client increase their intake of foods rich in
- A. Fiber.
- B. Saturated fats.
- C. Calcium.
- D. Potassium.
Correct Answer: A
Rationale: Fiber aids digestion, often slowed in hypothyroidism. Saturated fats, calcium, and potassium are not specifically indicated.