A nurse is caring for a client in the outpatient health clinic.
Encourage naps during the day when client is tired.
Advise client to rise slowly from sitting position.
Instruct client to avoid foods that have been fermented or aged.
Encourage client to sleep until later in the morning.
Encourage a regular sleep-wake schedule.
Advise client to notify provider if pregnant.
Encourage high-calorie finger foods.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}
Rationale:
• Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep quality and reduce trazodone’s effectiveness in reestablishing a normal sleep pattern.
• Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension, particularly when therapy is initiated. Educating the client to change positions slowly helps prevent dizziness and potential falls caused by sudden drops in blood pressure.
• Instruct client to avoid foods that have been fermented or aged: This instruction applies to MAOIs due to the risk of hypertensive crisis from tyramine, but trazodone is a serotonin antagonist and reuptake inhibitor, not an MAOI.
• Encourage client to sleep until later in the morning: Oversleeping disrupts the circadian rhythm and may worsen fatigue. The goal is to maintain a stable sleep-wake cycle to enhance mood and energy regulation.
• Encourage a regular sleep-wake schedule: Establishing consistent sleep routines supports trazodone’s sedative effects and helps regulate the client’s circadian rhythm, improving overall sleep quality without disrupting normal activity patterns.
• Advise client to notify provider if pregnant: Trazodone is classified as pregnancy category C, meaning potential fetal risks exist. The client should notify the provider to evaluate the safety of continuing or adjusting medication during pregnancy.
• Encourage high-calorie finger foods: The client’s BMI has decreased, and trazodone may cause appetite suppression. Offering convenient, calorie-dense snacks helps maintain adequate nutrition and prevents further weight loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A client who has dementia and is incontinent of urine: Cognitive impairment and incontinence significantly increase the risk for pressure injuries. Dementia may limit mobility and the ability to communicate discomfort, while moisture from incontinence leads to skin breakdown, making this client the highest risk.
B. A client who has had a recent myocardial infarction: While immobility after a myocardial infarction can contribute to pressure injury risk, this client typically has fewer direct risk factors compared with incontinence and cognitive impairment.
C. A client who has a T-tube following an open cholecystectomy: Postoperative clients with a T-tube are at moderate risk due to temporary immobility, but they usually maintain mobility and can reposition, reducing overall risk compared with incontinent or cognitively impaired clients.
D. A client who is 2 days postoperative following orthopedic surgery: Early postoperative orthopedic clients are at risk due to immobility, but with appropriate repositioning, pressure-relieving devices, and monitoring, their risk is generally lower than a client with incontinence and dementia.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.
B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.
C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.
D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.
E. Infuse the blood over 4 hr: Each unit of packed RBCs should be transfused within no more than 4 hours to reduce the risk of bacterial contamination and hemolysis from prolonged infusion.
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