A nurse is assessing a client's sleep-wake patterns during an initial clinic visit. Which of the following findings should the nurse report to the provider?

The client reports frequently having a headache in the morning.

The client reports having vivid dreams about their childhood.

The client reports taking 30 min to fall asleep on average.

The client reports sleeping about 7 hr on average.

Answer and Explanation

The Correct Answer is A

A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.

B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.

C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.

D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.

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Correct Answer is C

Explanation

A. Double-bag the linens: Double-bagging is no longer a standard requirement unless the outside of the primary bag is visibly soiled or the bag is punctured. Modern infection control guidelines focus on the integrity of a single, sturdy, leak-proof bag to reduce waste and cost.

B. Rinse the linens prior to removing them from the client's room: Rinsing the linens is not required when removing soiled linens. The main concern is preventing contamination, and double-bagging ensures that the linens are safely contained.

C. Tie the linens' bag securely at the top: The primary goal of isolation protocol is to contain the pathogen within the designated "dirty" area. By tying the bag securely, the nurse ensures that no contaminated fluid or air is released as the bag is moved through the hallways of the facility. Standard practice requires placing linens in a leak-proof laundry bag labeled for biohazardous or contaminated materials.

D. Wear sterile gloves when handling the linens: Sterile gloves are not necessary for handling soiled linens in contact precautions. Clean gloves are sufficient to handle linens. Sterile gloves are typically used for invasive procedures, not for routine linen handling.

A. Read the medication label twice prior to administration. B. Ask the client if they have ever taken a similar medication. C. Use one patient identifier prior to medication administration. D. Access the online drug formulary for an unfamiliar medication.

Correct Answer is D

Explanation

A. Read the medication label twice prior to administration: Best practice requires reading the label three times (when retrieving, preparing, and before administering), so reading it only twice is insufficient for safety.

B. Ask the client if they have ever taken a similar medication: While helpful, this does not replace the need for the nurse to verify the medication's action, side effects, and interactions independently.

C. Use one patient identifier prior to medication administration: Safe practice requires using two patient identifiers (e.g., name and date of birth), so using only one is inadequate and unsafe.

D. Access the online drug formulary for an unfamiliar medication: This ensures the nurse understands the medication's purpose, dosage, side effects, and contraindications, which is critical for safe first-time administration.

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A nurse is assessing a client's sleep-wake patterns during an initial clinic visit. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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