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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.

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Correct Answer is B

Explanation

A. Record a palpable systolic pressure of 90 mm Hg is premature because the nurse has not yet completed the process of determining the systolic blood pressure.

B. Inflate blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse disappears to ensure accurate measurement of the systolic blood pressure.

C. Release the manometer valve immediately would not allow the nurse to accurately determine the systolic blood pressure. The valve should be released slowly to palpate the return of the pulse.

D. Document the absence of the radial pulse is unnecessary because the disappearance of the pulse is a normal part of the procedure when obtaining a systolic blood pressure by palpation.

A. Obtain the specimen from the client's current bowel movement. B. Withhold specimen collection until tarry black stool is observed. C. Contact the healthcare provider before obtaining the specimen. D. Wait to obtain the specimen until observable blood is present.

Correct Answer is A

Explanation

A. Obtain the specimen from the client's current bowel movement is the correct action. Occult blood can be present even in normal-appearing stool. The nurse should obtain the specimen from the current bowel movement, as it is part of the protocol for testing for hidden blood in the stool. The stool does not need to be tarry or black to test for occult blood.

B. Withhold specimen collection until tarry black stool is observed is incorrect. Tarry black stools often indicate the presence of digested blood, but occult blood testing is designed to detect blood that may not be visible to the naked eye, even in normal-colored stool.

C. Contact the healthcare provider before obtaining the specimen is unnecessary. The nurse can proceed with the collection as per the standard procedure without needing to contact the healthcare provider, unless there is a specific reason to do so.

D. Wait to obtain the specimen until observable blood is present is incorrect. The purpose of an occult blood test is to detect hidden (occult) blood, which may not be visible to the eye. The nurse should not wait for visible blood to appear before collecting the specimen.

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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

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is B

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

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?

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?

A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

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?

Exhibits

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