A nurse is teaching a client about the sleep-wake cycle. The nurse should include that which of the following factors can interfere with the sleep-wake cycle? (Select All that Apply)

A bright light

Drinking caffeinated beverages in the evening

A 20 min nap during the day

Emotional stress

A regular bedtime schedule

Answer and Explanation

Correct Answer : A,B,C,D

A) Bright light: Exposure to bright light, especially in the evening or at night, can interfere with the body's production of melatonin, a hormone that regulates the sleep-wake cycle. Bright light exposure can disrupt circadian rhythms, making it more challenging to fall asleep and stay asleep.

B) Drinking caffeinated beverages in the evening: Caffeine is a stimulant that can interfere with sleep by blocking the effects of adenosine, a neurotransmitter that promotes sleepiness. Consuming caffeinated beverages in the evening can delay the onset of sleep and reduce overall sleep duration.

C) A 20-minute nap during the day: While short naps can be beneficial for some individuals, especially if they are sleep-deprived, napping for too long or too late in the day can disrupt the body's natural sleep-wake cycle. Short naps can be refreshing, but longer or late-day naps can make it harder to fall asleep at night.

D) Emotional stress: Stress and anxiety can trigger the body's "fight or flight" response, leading to increased alertness and difficulty relaxing or falling asleep. Chronic stress can disrupt the sleep-wake cycle, leading to difficulty initiating or maintaining sleep and resulting in poor sleep quality.

E) A regular bedtime schedule: Having a consistent bedtime schedule can actually help regulate the sleep-wake cycle by reinforcing the body's internal clock. Going to bed and waking up at the same time each day, even on weekends, can help improve sleep quality and make it easier to fall asleep and wake up naturally.

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Correct Answer is C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

A. The client reports numbness at the site. B. Purulent drainage noted from the site C. Skin over the site is sloughing D. The vein appears cord-like

Correct Answer is B

Explanation

A) The client reports numbness at the site: Numbness at the insertion site is not a typical finding of infection. It may indicate nerve damage or another issue but is not specific to infection.

B) Purulent drainage noted from the site: Purulent drainage, characterized by pus-like discharge, is a common sign of infection at the insertion site of an intravenous catheter. It suggests the presence of bacteria and inflammation at the site.

C) Skin over the site is sloughing: Sloughing of the skin may occur with severe tissue damage but is not specific to infection. It could indicate other complications such as tissue necrosis or chemical irritation.

D) The vein appears cord-like: A cord-like appearance of the vein, known as thrombophlebitis, can occur with or without infection. It indicates inflammation and clot formation within the vein, which can be a complication of intravenous catheter insertion, but it does not specifically indicate infection.

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A nurse is teaching a client about the sleep-wake cycle. The nurse should include that which of the following factors can interfere with the sleep-wake cycle? (Select All that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect?

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?

A home health nurse is teaching about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following finding

A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine?

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?