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A nurse is providing education to a client diagnosed with insomnia. What sleeppromoting techniques would the nurse suggest to help the client's condition? Select all that apply.

Avoid caffeine beverages at least 4 to 6 hours before bedtime.

Take 2-hour naps during the day.

Obtain a massage.

Maintain a regular sleep-wake cycle.

Engage in a regular exercise routine at least 3 hours before going to bed.

Answer and Explanation

Correct Answer : A,D,E

correct answers are:

A. Avoid caffeine beverages at least 4 to 6 hours before bedtime.

D Maintain a regular sleep-wake cycle.

E Engage in a regular exercise routine at least 3 hours before going to bed.

The nurse would suggest the client avoid caffeine beverages because caffeine is a stimulant that can keep the client awake. The nurse would also recommend maintaining a regular sleep-wake cycle because the body responds to consistent sleep and wake times, which can help promote restful sleep. Engaging in a regular exercise routine at least 3 hours before going to bed can help promote sleep by reducing stress and anxiety, and improving physical health. However, the nurse would not recommend taking 2-hour naps during the day, as this can interfere with the ability to sleep at night, and obtaining a massage, although it may be relaxing, may not directly promote sleep.

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Correct Answer is C

Explanation

A.This option is incorrect because a PVR of 400 mL is significantly higher than normal. Documenting without further intervention could lead to complications if the high residual volume persists.

B.While an external catheter may be beneficial for managing incontinence or monitoring urine output, it does not address the underlying issue of urinary retention. An external catheter would not relieve the retained urine in the bladder.

C.A post-void residual (PVR) of 400 mL is abnormally high, indicating that the bladder is not emptying effectively, which can lead to discomfort, urinary tract infection (UTI), and potential kidney issues if left untreated. An in-and-out catheterization allows for temporary relief by emptying the bladder and can also help prevent bladder distention. Contacting the physician to report the findings and obtain an order is appropriate to manage this condition safely.

D. Encouraging the client to attempt voiding again without intervention may not be effective in reducing the high PVR. This delay could increase the risk of bladder distention and discomfort.

A. Document and describe interventions performed by the previous shift nurse. B. Use standard terminology and commonly used medical abbreviations. C. Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response. D. Do not document nursing interventions ahead of time before performing them. E. Document nursing interventions performed by the nurse who is documenting.

Correct Answer is ["B","C","D","E"]

Explanation

correct answers are:

B Use standard terminology and commonly used medical abbreviations.

C Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.

D o not document nursing interventions ahead of time before performing them.

E Document nursing interventions performed by the nurse who is documenting.

Nurses play a crucial role in patient care and documentation guidelines are important to ensure accuracy, completeness, and continuity of care. Using standard terminology and commonly used medical abbreviations is important to ensure that documentation is clear, concise, and easily understood by all members of the healthcare team. This practice helps avoid confusion, facilitates communication, and ensures that all healthcare professionals can accurately interpret and act upon the documented information.

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A nurse is providing education to a client diagnosed with insomnia. What sleeppromoting techniques would the nurse suggest to help the client's condition? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

Correct Answer is C

Explanation

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

Which of the following would be falsification of health records? Select all that apply.

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