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

Bedtime

Use of chronic devices

Evening meal

Medication

Caffeine use

Exercise schedule

Answer and Explanation

Correct Answer : C,F

A. Bedtime: The client’s bedtime of 2330 has remained unchanged despite the shift in work hours, providing some stability to the circadian rhythm. A consistent bedtime typically supports sleep regulation rather than disrupting it. Although the new routine may affect sleep pressure, the bedtime is not the primary contributor to the new difficulties falling asleep.

B. Use of chronic devices: The client turns off their phone at 2230, limiting blue-light exposure well before bedtime. There is no indication of prolonged screen use or other electronic stimulation that would interfere with melatonin release. With the device turned off an hour before bed, this factor is unlikely to be influencing the client’s disrupted sleep.

C. Evening meal: The client now eats dinner late in the evening after a 1200–2000 work shift, placing the meal close to their 2330 bedtime. Eating late can increase gastrointestinal activity and delay the body’s transition into restful sleep, contributing to both difficulty falling asleep and nighttime awakenings.

D. Medication: The client’s medications ethinyl estradiol/desogestrel and ferrous sulphate have remained consistent for months without changes in timing or dosage. These medications are not known to disrupt sleep when taken as prescribed and do not coincide with the recent onset of nighttime symptoms.

E. Caffeine use: Although the client now drinks 2 to 3 cups of coffee, it is consumed early in the morning and remains outside the usual window in which caffeine impacts nighttime sleep. Morning intake allows adequate time for caffeine metabolism before bedtime. The timing makes it a less significant factor in the client’s difficulties initiating and maintaining sleep.

F. Exercise schedule: The client exercises immediately after a shift that ends at 2000, pushing vigorous activity close to bedtime. Late-evening exercise can increase sympathetic activity and core body temperature, which can interfere with the body’s ability to relax and initiate sleep.

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Correct Answer is A

Explanation

A. Infuse 0.9% sodium chloride IV: The first action in a suspected hemolytic transfusion reaction is to stop the blood transfusion and maintain IV access with 0.9% sodium chloride. This helps prevent hypotension, supports renal perfusion, and allows for administration of fluids to reduce the risk of acute kidney injury from hemolyzed red blood cells.

B. Administer an antipyretic: While fever may occur during a hemolytic reaction, administering an antipyretic is not the priority. Immediate supportive measures, including stopping the transfusion and maintaining IV access, take precedence to prevent severe complications.

C. Decrease the infusion rate to 75 mL/hr: Slowing the transfusion is unsafe in the setting of a hemolytic reaction because the transfusion itself is causing a potentially life-threatening response. The infusion must be stopped entirely, not slowed.

D. Place the client in a left lateral position: Positioning may be used in certain emergencies, such as to prevent aspiration or improve hemodynamics, but it is not a specific intervention for hemolytic transfusion reactions. The priority is to stop the transfusion and initiate fluid resuscitation.

A. Urine specific gravity of 1.028 (1.005 to 1.03) B. Urine output of 250 mL/hr C. Serum sodium of 115 mEq/L (136 mEq/L to 145 mEq/L) D. Blood glucose of 198 mg/dL (less than 200 mg/dL)

Correct Answer is B

Explanation

A. Urine specific gravity of 1.028 (1.005 to 1.03): A urine specific gravity in this range is within normal limits, indicating concentrated urine. In diabetes insipidus, urine is typically very dilute with a specific gravity below 1.005, reflecting excessive water loss, so this finding does not indicate DI.

B. Urine output of 250 mL/hr: Excessive urine output is a hallmark of diabetes insipidus, especially in the context of a recent head injury. High-volume, dilute urine (polyuria) occurs due to a deficiency of antidiuretic hormone or kidney insensitivity to it. This finding alerts the nurse to the early development of DI and the need for intervention.

C. Serum sodium of 115 mEq/L (136 mEq/L to 145 mEq/L): Low sodium indicates hyponatremia, which is not typical of DI. In fact, DI usually causes hypernatremia due to free water loss, making this finding inconsistent with the expected laboratory changes in DI.

D. Blood glucose of 198 mg/dL (less than 200 mg/dL): Mildly elevated blood glucose may indicate stress hyperglycemia but is unrelated to the pathophysiology of diabetes insipidus. Glucose levels do not provide a reliable indication of DI development.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

Correct Answer is A

Explanation

A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI?

Correct Answer is B

Explanation

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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