During a sleep history evaluation, which statement by the client requires further follow-up?

I usually fall asleep after about 15 minutes.

I wake up to urinate once each night.

I often wake up feeling tired in the morning.

I have a regular nighttime routine.

Answer and Explanation

The Correct Answer is C

This statement requires further follow-up because it indicates that the client may have poor sleep quality or quantity, which can affect their health and well-being. According to, the main components of the sleep history include defining the specific sleep problem, assessing the disorder’s clinical course, differentiating between sleep disorders, evaluating the sleep-wakefulness patterns, questioning the bed partner, and obtaining a family history of sleep disorders.

Choice A is wrong because falling asleep after about 15 minutes is normal and indicates good sleep hygiene.

Choice B is wrong because waking up to urinate once each night is not uncommon in older adults and does not necessarily disrupt their sleep continuity.

Choice D is wrong because having a regular nighttime routine is beneficial for promoting relaxation and preparing for sleep.

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Correct Answer is D

Explanation

You need to speak to the designated hospital contact. This is because the nurse has a duty to protect the client’s privacy and confidentiality, and cannot disclose any information about the client’s diagnosis or condition to the reporter without the client’s consent.

The nurse should refer the reporter to the hospital’s public relations department or spokesperson, who is authorized to handle such inquiries.

Choice A is wrong because it implies that the client’s healthcare provider can release the information without the client’s consent, which is not true.

Choice B is wrong because it confirms that the client is on the unit, which is a violation of the client’s privacy.

Choice C is wrong because it gives false information about the client’s status, which is unethical and unprofessional.

A. Obtain a sputum culture specimen. B. Administer azithromycin 500mg IVPB. C. Encourage coughing and deep breathing. D. Offer clear liquids for the client to drink.

Correct Answer is A

Explanation

The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.

This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.

Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.

Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.

Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.

Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.

Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to

1.2 mg/dL.

Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.

The nurse should monitor these levels and report any abnormalities to the health care provider.

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During a sleep history evaluation, which statement by the client requires further follow-up?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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