A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

Caffeine use

Evening meal

Use of electronic devices

Exercise schedule

Bedtime Medications

Answer and Explanation

Correct Answer : A,C

A.   Caffeine is a stimulant and can interfere with sleep, especially if consumed in the afternoon or evening. It can lead to difficulty falling asleep and disrupt the sleep cycle.
B.   While heavy meals close to bedtime can cause discomfort or indigestion, a light evening meal generally does not significantly interfere with sleep for most individuals.
C.   The use of electronic devices, particularly before bedtime, can interfere with sleep due to the blue light emitted by screens. This light can suppress the production of melatonin, a hormone that helps regulate sleep.
D.   Regular exercise generally promotes better sleep. However, vigorous exercise close to bedtime may interfere with sleep due to the increase in adrenaline, but this is not always the case.
E.   The medications taken by the individual do not interfere with sleep.

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Correct Answer is C

Explanation

A. Wearing well-fitted shoes at home helps prevent slips and falls.

B. Placing throw rugs over electrical cords increases the risk of tripping.

C. Area rugs with rubber backs prevent slipping, reducing the risk of falls in a postoperative client.

D. Marking doorways with tape is not necessary for a client after knee replacement and may be more applicable for clients with visual impairments.

A. Obtain a serum WBC count. B. Insert indwelling urinary catheter. C. Make the client NPO. D. Initiate antibiotic therapy. E. Obtain a consent for surgery. F. Withhold metoprolol. G. Administer acetaminophen. H. Collect urine for urinalysis and culture and sensitivity. I. Obtain chest x-ray.

Correct Answer is ["A","D","G","H"]

Explanation

A. Obtain a serum WBC count: A WBC count will help assess for infection, as the client presents with fever, confusion, and urinary symptoms. Elevated WBC could suggest a urinary tract infection (UTI) or other infection.
B. Insert indwelling urinary catheter: An indwelling catheter is not immediately necessary unless the client is unable to void or requires continuous monitoring. Non-invasive methods like obtaining a urine sample for analysis would be a priority.
C. Make the client NPO: There is no indication that the client requires NPO status at this time. Unless surgery or another procedure is planned, this is not necessary.
D. Initiate antibiotic therapy: Given the client's symptoms (fever, confusion, urinary frequency, urgency, and dark urine), a UTI or other infection is likely. Antibiotics are needed to treat the suspected infection.
E. Obtain a consent for surgery: There is no indication that surgery is needed based on the current clinical information. The primary concern is infection, not surgical intervention.
F. Withhold metoprolol: While metoprolol may lower blood pressure, there is no indication to withhold it at this time. The client’s blood pressure is already low, and withholding this medication could worsen hypotension. Any changes in the medication regimen should be made based on further evaluation by the provider.
G. Administer acetaminophen: Acetaminophen is indicated to help reduce the client's fever (39.3°C/102.7°F). Managing the fever will help improve comfort and prevent complications like delirium.
H. Collect urine for urinalysis and culture and sensitivity: Urine analysis and culture will help confirm the presence of a UTI, identify the causative pathogen, and guide appropriate antibiotic therapy.
I. Obtain chest x-ray: A chest x-ray is not necessary unless there is a suspicion of a respiratory infection, such as pneumonia. The symptoms are more consistent with a UTI or systemic infection, so a chest x-ray is not a priority.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is caring for a client in an outpatient clinic. Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse in the emergency department (ED) is caring for an older adult client. Exhibits Which of the following prescriptions from the provider should the nurse anticipate? Select all that apply.

Correct Answer is ["A","D","G","H"]

Explanation

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A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?

A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred?

A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?

A nurse is caring for a client in an outpatient clinic.

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.