A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will have a cup of hot cocoa immediately before bedtime."

I will no longer have a glass of wine before bedtime."

"I will walk briskly for 30 minutes before bedtime."

"I will do my muscle relaxation techniques each afternoon."

Answer and Explanation

The Correct Answer is B

A.   Consuming hot cocoa, especially if it contains caffeine or sugar, is generally not advisable before bedtime. Caffeine is a stimulant that can interfere with the ability to fall asleep, and sugar can lead to disruptions in sleep. Even if the hot cocoa is caffeine-free, having a liquid right before bed can cause frequent awakenings during the night.
B.   Alcohol can initially make a person feel drowsy, but it often disrupts sleep patterns later in the night, leading to poorer quality sleep. Reducing or eliminating alcohol consumption before bedtime can improve sleep quality and promote better rest.
C.   While regular physical activity is beneficial for sleep, exercising too close to bedtime can actually be stimulating and make it harder to fall asleep. It is generally recommended to complete vigorous exercise at least 2-3 hours before going to bed to avoid interfering with sleep.
D.   Muscle relaxation techniques, such as progressive muscle relaxation, are effective for reducing stress and improving sleep quality. However, performing these techniques in the afternoon is less beneficial compared to doing them closer to bedtime.

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Correct Answer is A

Explanation

A. A urine output of 175 mL over 8 hours is significantly below normal, which is generally considered less than 0.5 mL/kg/hr in adults (the normal range is about 0.5-1.5 mL/kg/hr). Reduced urine output can be indicative of acute kidney injury or worsening renal function, and it needs prompt evaluation and intervention.
B. This finding is generally not urgent but could be noted. Strong-smelling urine, especially in the morning, may be due to concentration of waste products overnight or dietary factors. While it might suggest dehydration or infection, it is less immediately concerning than changes in urine output. If accompanied by other symptoms such as pain, fever, or changes in urine color, it might warrant further investigation.
C. This finding is typically within normal limits and may not need immediate reporting. Normal urine output is about 800-2,000 mL per day. An output of 2,200 mL is slightly elevated but still within the normal range, depending on fluid intake.
D. This finding is generally not urgent but worth noting. Cloudy urine can result from the presence of cells, bacteria, or other substances. It may become cloudy after standing due to the formation of crystals or precipitation of substances.

A. Check the stockings for wrinkles. B. Measure the size of the client's foot. C. Remove the stockings once each day. D. Apply the stockings while the client is sitting in a chair.

Correct Answer is A

Explanation

A. Checking the stockings for wrinkles is an important action. Wrinkles or folds in the stockings can create areas of increased pressure, which might lead to discomfort or skin breakdown and reduce the effectiveness of the stockings in preventing DVT. Ensuring that the stockings are smooth and free from wrinkles helps maintain proper compression and comfort.
B. Measuring the size of the client's foot is not typically required for properly fitting antiembolic stockings. The key measurements for antiembolic stockings are usually related to the calf, thigh, and sometimes the knee, not the foot.
C. Removing the stockings once each day is not usually recommended unless specifically instructed by a healthcare provider. Antiembolic stockings are generally worn continuously throughout the day and removed only for specific reasons, such as skin assessment or hygiene.
D. Applying the stockings while the client is sitting in a chair is not the preferred method. Antiembolic stockings should be applied while the client is lying down or in a supine position. This helps ensure that the stockings are applied evenly and that they provide consistent compression without causing undue pressure or discomfort.

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A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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