Nokea
The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?
- A. I will avoid naps later in the day.'
- B. I will keep the bedroom temperature cool.'
- C. I will read in bed before trying to go to sleep.'
- D. I will try to go to bed and wake up at the same time each day.'
Correct Answer: C
Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.
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The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed
- A. removing the protective gown with the contaminated side facing away from the body
- B. placing a surgical mask on the client before transport outside of the client's room
- C. removing the N95 respirator mask while inside the client's room
- D. keeping the door to the client's room closed at all times
Correct Answer: C
Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B, D) follow correct infection control protocols.
The nurse is talking with a client who has a new prescription for metronidazole. Which of the following statements by the client would require follow up?
- A. I can continue to drink a glass of wine with dinner while I am taking this medication'
- B. I might experience a metallic taste in my mouth while I am taking this medication'
- C. I should not be concerned if my urine turns a dark color while taking this medication'
- D. I will immediately contact my health care provider if I experience a rash or skin peeling.'
Correct Answer: A
Rationale: Drinking alcohol while taking metronidazole can cause a disulfiram-like reaction, requiring follow-up. Metallic taste and dark urine are common side effects, and reporting rash or peeling is appropriate.
An adult woman who has multiple sclerosis (MS) asks the nurse why she developed multiple sclerosis. What information should the nurse include when responding?
- A. MS usually follows a streptococcal infection.
- B. MS is an autoimmune condition.
- C. MS occurs more often among persons who have had chickenpox.
- D. MS may be related to mosquito bites.
Correct Answer: B
Rationale: Multiple sclerosis is an autoimmune disorder where the immune system attacks myelin in the central nervous system, unlike infections or mosquito bites.
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway
- B. Call for help
- C. Establish that the client is unresponsive
- D. See if anyone saw the client fall
Correct Answer: C
Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.
The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?
- A. Administer oxygen
- B. Assess the client's breath sounds
- C. Initiate cardiac monitoring
- D. Insert a peripheral IV catheter
Correct Answer: B
Rationale: Assessing breath sounds is the first step to evaluate the extent of fluid overload and guide interventions in heart failure. Oxygen , monitoring , and IV insertion follow based on findings.