A nurse is providing teaching about measures to promote sleep with a client who has Insomnia. Which of the following client statements Indicates an understanding of the teaching?

"I can exercise as late as 1 hour before bedtime."

"I should reduce my fluid intake 2 hours before bedtime."

"I should take a 1 hour nap each day.

"I can eat a large meal as late as 1 hour before bedtime."

Answer and Explanation

The Correct Answer is B

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

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Correct Answer is A

Explanation

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

A. "Contacted the provider to report client findings." B. "Reports stomach pain as 3 on a pain scale of 0 to 10." C. "Vomited 120 mL of clear, yellow emesis." D. "Denies further nausea or vomiting since antiemetic administration.

Correct Answer is D

Explanation

A. "Contacted the provider to report client findings." – This is an example of collaboration or communication, not direct implementation of care.

B. "Reports stomach pain as 3 on a pain scale of 0 to 10." – This is assessment, not implementation.

C. "Vomited 120 mL of clear, yellow emesis." – This is also assessment (objective data collection).

D. "Denies further nausea or vomiting since antiemetic administration." – This is implementation, as it evaluates the effect of an intervention (antiemetic administration).

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A nurse is providing teaching about measures to promote sleep with a client who has Insomnia. Which of the following client statements Indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Correct Answer is A

Explanation

A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?

Correct Answer is D

Explanation

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