The home health nurse is visiting an older adult client whose caregiver reports that the client has been anxious and disoriented in the morning. The caregiver also informs the nurse that the client gets up frequently to use the bathroom during the night. The client's current medications include hydralazine 75 mg by mouth daily, furosemide 40 mg by mouth daily, and potassium chloride 20 mEq by mouth daily. Which recommendation will the nurse provide the caregiver to decrease the disruption of sleep?

Offer the client iced tea before bed.

Suggest the client sleep without socks.

Have the client take a diuretic in the morning.

Encourage the client to take frequent naps during the day

Answer and Explanation

The Correct Answer is C

A. Offering iced tea before bed is not appropriate because tea contains caffeine, which can further disrupt sleep.
B. Sleeping without socks has no relevance to sleep disruption related to nocturia (frequent urination at night).
C. Having the client take a diuretic (furosemide) in the morning is the most appropriate intervention. Diuretics increase urine output, and taking them later in the day can lead to nocturia, which disrupts sleep and may contribute to confusion or disorientation in older adults.
D. Encouraging frequent naps during the day can interfere with the client’s nighttime sleep pattern, potentially worsening insomnia or nighttime disorientation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Battery involves intentional physical harm or offensive contact, which is not applicable here as the nurse did not assist but did not intentionally harm the client.
B. Fraud involves deception for personal gain, which is not relevant in this situation.
C. Assault is an intentional act causing fear of harmful or offensive contact, which did not occur here.
D. Negligence occurs when a nurse fails to provide the standard of care, such as not assisting a postoperative client with ambulation, resulting in harm—in this case, the client’s fall and fractured hip.

A. pain B. minor bleeding C. discomfort D. infection

Correct Answer is D

Explanation

A. Pain is expected but usually temporary and less harmful.
B. Minor bleeding is common and generally not serious.
C. Discomfort is temporary and less significant compared to other risks.
D. Infection poses the greatest harm because it can lead to serious complications such as bloodstream infections.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse does not assist with ambulation of a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse?

Correct Answer is D

Explanation

A nurse is preparing to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

Correct Answer is D

Explanation

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?

The nurse is caring for a client who has been prescribed an enteric-coated drug. Which should the nurse include when teaching the client proper administration of this drug?

client scheduled for complex heart surgery has been reading their religious text for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the client?

A nurse manager is conducting an in-service education program for a group of staff nurses on developing cultural competence. The nurse manager determines that the educational program was successful based on which statement by the group?

When providing culturally competent care to a client, which aspect of care is most important for the nurse to keep in mind?

When assisting a client from the bed into a wheelchair, the nurse assesses the client on standing and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation?

A client is diagnosed with a terminal illness. Who is usually responsible for deciding what, when, and how the client should be told?