Nokea
The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?
- A. serotonin
- B. cortisone
- C. alcohol
- D. narcotics
Correct Answer: A
Rationale: Serotonin is a substance that is in the body and promotes sleep. Serotonin might play a role in synthesis of a hypnogenic factor that directly causes sleep. Drugs and alcohol can disrupt REM sleep, although they might accelerate the onset of sleep.
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The hospitalized client with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client's skin integrity? Select all that apply.
- A. Massage vigorously over bony prominences daily
- B. Wear sterile gloves when inspecting the client's skin
- C. Apply a moisturizing lotion to bony prominences
- D. Instruct the client to change position every 2 hours
- E. Apply an overhead trapeze to the client's bed
- F. Apply a barrier cream if the client is incontinent of stool
Correct Answer: C,D,E,F
Rationale: C: Moisturizers prevent dry skin. D: Repositioning improves circulation. E: Trapezes reduce friction during movement. F: Barrier creams protect against incontinence. A: Vigorous massage causes tissue trauma. B: Sterile gloves are unnecessary unless breakdown exists.
Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Compliance or performance at the minimally acceptable level is not considered quality care.
The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
- A. Perform hand hygiene and don gloves.
- B. Pinch the lens over the pupil and remove.
- C. Place the lens in a sterile container with normal saline.
- D. Irrigate the eye with normal saline to loosen the lens.
- E. Instruct the client to look up when removing the lens.
Correct Answer: A,C,E
Rationale: A: Hand hygiene and gloves prevent infection. C: Normal saline keeps lenses moist if no lens solution is available. E: Looking up aids safe lens removal. B: Pinching over the pupil risks corneal abrasion. D: Irrigation could damage or lose the lens.
The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
- A. Nasogastric tube to low intermittent suction has small amounts of dark bloody returns.
- B. Oxygen saturation level is 92%, and oxygen by nasal cannula is set at 2 liters.
- C. The incisional dressing has a 25-cent-piece-sized shadow of new drainage.
- D. The Jackson-Pratt drain is round in shape with 30 mL serosanguineous drainage.
Correct Answer: D
Rationale: D: A round JP drain indicates lost suction, requiring immediate emptying and compression. A: Minor bloody NG returns are normal post-surgery. B: 92% saturation is adequate. C: Small drainage is monitorable.
The client has asked if you would be able to offer any alternative or complementary therapy during their hospitalization. Which of the following would be appropriate to suggest? A. Physical therapy,B. Music therapy, C. Psychiatric therapy, D. Occupational therapy, E. Pet therapy
- A. B and E
- B. A and E
- C. C and D
- D. B and C
Correct Answer: A
Rationale: Music therapy and pet therapy are two forms of alternative or complementary therapy that may improve the client's condition and level of comfort. Physical, occupational, and/or psychiatric therapy are treatments that may be part of the client's care plan, and they are not considered complementary or alternative treatments. Additionally, they usually require a prescription or referral where music therapy and pet therapy typically do not.