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Exhibits

Which other recommendation(s) could the nurse give to help the client have better sleep? Select all that apply.

Avoid naps

Eat a heavy meal before bed

Watch television in bed to fall asleep

Exercise in the evening

Try to go to bed and awaken at the same time every day

Avoid alcohol in the evening

Take an analgesic before bed

Answer and Explanation

Correct Answer : A,E,F

A. Avoid naps – Napping during the day, especially late in the afternoon or evening, can interfere with the ability to fall asleep at night. It is generally recommended to avoid naps if experiencing insomnia.

B. Eat a heavy meal before bed – Eating a heavy meal before bed can cause discomfort and indigestion, making it harder to sleep. It is better to have a light snack if needed.

C. Watch television in bed to fall asleep – Engaging in stimulating activities like watching television in bed can make it harder to relax and fall asleep. It is recommended to reserve the bed for sleep and intimacy only to associate it with rest.

D. Exercise in the evening – Exercise increases alertness and can elevate body temperature, making it more difficult to fall asleep if done too close to bedtime. Exercise should be completed earlier in the day for better sleep quality.

E. Try to go to bed and awaken at the same time every day – Consistency in sleep-wake times helps regulate the body's internal clock, improving sleep quality and promoting better sleep hygiene.

F. Avoid alcohol in the evening – Alcohol can initially make someone feel sleepy but disrupts the later stages of sleep, leading to poor sleep quality. Avoiding alcohol, especially close to bedtime, is important for better rest.

G. Take an analgesic before bed – Unless there is a specific medical reason, taking an analgesic (such as pain medication) before bed is not recommended unless prescribed by a healthcare provider.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Warm, dry skin with a fever of 100.0° F (37.8° C) is not directly related to the need for frequent turning. A fever and warm, dry skin may indicate an infection or another underlying condition, but it does not prioritize the need for turning in the context of pressure injury prevention.

B. 4+ pitting edema of both lower extremities may indicate fluid retention, but it is not as directly related to the risk of developing pressure injuries. Although edema can impact skin integrity, the Braden scale score is a more reliable indicator for turning schedules to prevent pressure ulcers.

C. A Braden risk assessment scale rating score of ten is the most important factor in determining the turning schedule. A score of ten indicates a high risk for developing pressure ulcers, which is directly related to the need for frequent repositioning to relieve pressure and prevent skin breakdown.

D. Hypoactive bowel sounds with infrequent bowel movements may be a concern for gastrointestinal function, but it does not directly affect the turning schedule. The Braden scale score is a better indicator for deciding how often the client needs to be turned to prevent pressure injuries.

A. Gives the client a hug and says, "It is okay to cry when you are sad." B. While touching the client's forearm, asks, "Would you like to talk about it?" C. "This is a bad time. I can see you are upset. I can come back later." D. "I am sorry to disturb you at a difficult time. This can wait until later."

Correct Answer is B

Explanation

A. Gives the client a hug and says, "It is okay to cry when you are sad" may seem comforting but could invade the client’s personal space and may not be appropriate in a professional setting without the client’s consent.

B. While touching the client's forearm, asks, "Would you like to talk about it?" is correct because it shows empathy, provides emotional support, and invites the client to share their feelings. The light touch conveys care without being intrusive.

C. "This is a bad time. I can see you are upset. I can come back later" dismisses the client’s emotional needs and prioritizes the nurse’s schedule over the client’s well-being.

D. "I am sorry to disturb you at a difficult time. This can wait until later" acknowledges the client’s emotions but does not provide immediate support or address their needs effectively.

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Exhibits Which other recommendation(s) could the nurse give to help the client have better sleep? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

Correct Answer is C

Explanation

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

To assess the quality of an adult client's pain, which approach should the nurse use?

When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in this client's teaching?

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

Exhibits

Which other recommendation(s) could the nurse give to help the client have better sleep? Select all that apply.