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The nurse knows that a patient taught sleep hygiene practices needs further instruction when he says
- A. Once I go to bed, I should get up if I am not asleep after 20 minutes.
- B. It’s okay to have my usual two glasses of wine in the evening before bed.
- C. A couple of crackers with cheese and a glass of milk may help to relax before bed.
- D. I should go to the gym earlier in the day so that I’m done at least 6 hours before bedtime.
Correct Answer: B
Rationale: The correct answer is B. Alcohol disrupts sleep architecture, making it counterproductive for sleep hygiene. Getting up after 20 minutes (A) is a recommended practice, and exercising early (D) promotes better sleep.
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A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
- A. Monitoring blood pressure
- B. Checking the activated partial thromboplastin time (aPTT)
- C. Assessing for signs of bleeding
- D. Measuring calf circumference
Correct Answer: C
Rationale: The correct answer is C: Assessing for signs of bleeding. This is the priority assessment because heparin therapy increases the risk of bleeding. Signs of bleeding include bruising, petechiae, blood in urine or stool, and excessive bleeding from wounds. Monitoring blood pressure (A) is important but not the priority in this situation. Checking aPTT (B) is important for evaluating the effectiveness of heparin therapy but does not take precedence over assessing for bleeding. Measuring calf circumference (D) is used to detect changes in calf size due to DVT but is not the priority assessment while the client is on heparin therapy.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?
- A. Encourage the client to walk for 5 minutes each hour.
- B. Refer the client for smoking cessation classes.
- C. Teach the client about factor V Leiden testing.
- D. Explain to the client that sometimes no cause for the disease is found.
Correct Answer: C
Rationale: The correct answer is C because teaching the client about factor V Leiden testing is important in this scenario. Factor V Leiden is a genetic mutation that increases the risk of blood clot formation, including pulmonary embolism. Since the client has no known risk factors for PE, testing for this specific genetic mutation can help identify an underlying cause. Encouraging walking (choice A) is generally beneficial but may not address the root cause. Referring for smoking cessation (choice B) is not relevant in this case. Explaining that sometimes no cause is found (choice D) is not proactive and may lead to missed opportunities for prevention.
Identify what short-term evaluation technique is appropriate to assess whether the patient has met the following learning goals.
- A. Demonstration
- B. Verbalization
- C. Selection
- D. Observation
Correct Answer: B
Rationale: Each learning goal requires a different evaluation technique: Demonstration for subcutaneous insulin injection, Verbalization for identifying side effects of Coumadin, Selection for choosing potassium-rich foods, Observation for verbalizing no shortness of breath, and Verbalization for stating readiness to change a dressing. The correct technique depends on the specific goal.
Persons at risk are the target population for cancer screening programs. Which asymptomatic patient(s) needs extra encouragement to participate in cancer screening? (Choose all that apply.)
- A. A 19-year-old white-American female who is sexually inactive for a Pap smear.
- B. A 35-year-old white-American female for an annual mammogram.
- C. A 45-year-old African-American male for an annual prostate-specific antigen.
- D. A 49-year-old African-American male for an annual fecal occult blood test.
Correct Answer: D
Rationale: African-American males are at higher risk for prostate and colorectal cancers, making regular screening crucial for early detection.
During a preoperative review of systems, the patient reveals a history of renal disease. This finding suggests the need for which preoperative diagnostic tests?
- A. ECG and chest x-ray
- B. Serum glucose and CBC
- C. ABGs and coagulation tests
- D. BUN, serum creatinine, and electrolytes
Correct Answer: D
Rationale: Renal disease necessitates evaluating kidney function through tests like BUN, serum creatinine, and electrolytes.