A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

"Can you describe your bedtime routine to me?"

"Do you have difficulty staying awake when you are driving?"

"Are there any specific factors that you think are affecting your ability to sleep?"

"When did you begin to have trouble sleeping?"

Answer and Explanation

The Correct Answer is B

A.   Understanding the client’s bedtime routine can provide insights into habits that might affect sleep quality, such as engaging in stimulating activities before bed or the absence of a calming pre-sleep routine. However, while useful for identifying lifestyle factors that could impact sleep, this question
B.   This question is highly important because difficulty staying awake while driving can indicate severe sleep disturbances that may pose safety risks. It helps identify whether the client is experiencing excessive daytime sleepiness, which can be a symptom of serious underlying conditions such as sleep apnea or other sleep disorders.
C.   This question aims to identify potential triggers or contributing factors to the client’s insomnia, such as stress, medications, or environmental issues. While this information is valuable for understanding and managing insomnia, it may not immediately address urgent concerns related to the client’s safety or overall well-being.
D.   Understanding the onset of sleep difficulties is important for diagnosing potential causes and determining the duration and pattern of insomnia. This information helps in identifying whether the problem is acute or chronic, but it may not be as immediately critical as addressing potential safety issues related to the client’s sleep disturbances.

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Correct Answer is A

Explanation

A. A urine output of 175 mL over 8 hours is significantly below normal, which is generally considered less than 0.5 mL/kg/hr in adults (the normal range is about 0.5-1.5 mL/kg/hr). Reduced urine output can be indicative of acute kidney injury or worsening renal function, and it needs prompt evaluation and intervention.
B. This finding is generally not urgent but could be noted. Strong-smelling urine, especially in the morning, may be due to concentration of waste products overnight or dietary factors. While it might suggest dehydration or infection, it is less immediately concerning than changes in urine output. If accompanied by other symptoms such as pain, fever, or changes in urine color, it might warrant further investigation.
C. This finding is typically within normal limits and may not need immediate reporting. Normal urine output is about 800-2,000 mL per day. An output of 2,200 mL is slightly elevated but still within the normal range, depending on fluid intake.
D. This finding is generally not urgent but worth noting. Cloudy urine can result from the presence of cells, bacteria, or other substances. It may become cloudy after standing due to the formation of crystals or precipitation of substances.

A. Verify tube placement B. Check the residual feeding contents C. Evaluate tolerance of feeding D. Administer the feeding

Correct Answer is A,B,D,C

Explanation

A. Verify tube placement: This is the first step to ensure that the tube is in the correct position and not in the lungs, which could lead to aspiration.

B. Check the residual feeding contents: This helps to assess gastric emptying and ensure that the stomach can tolerate the feeding. If there is a large amount of residual, the feeding may be delayed or the rate may need to be adjusted.

D. Administer the feeding: Once tube placement is confirmed and residual contents are assessed, the feeding can be administered at the prescribed rate.

C. Evaluate tolerance of feeding: After the feeding is complete, it's important to monitor the client for signs of tolerance, such as the absence of nausea, vomiting, or abdominal distension.

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A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps, placing them in the selected order of performance. All steps must be used.)

Correct Answer is A,B,D,C

Explanation

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A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

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