The nurse is assessing a client's sleep patterns. Which statement made by the client would require additional questioning by the nurse? "My partner tells me that:

I snore so loudly that I wake her up several times a night."

neither of us sleeps well after we have a big fight."

I sleep so soundly it's like waking the dead to get me up."

she's heard me tell jokes in my sleep."

Answer and Explanation

The Correct Answer is A

A. This statement suggests that the client may have sleep-disordered breathing, such as obstructive sleep apnea, which can disrupt the client's sleep patterns and affect their overall sleep quality. The nurse may want to inquire further about the frequency and severity of the snoring, as well as any associated symptoms such as daytime fatigue or observed pauses in breathing during sleep.
B. This statement indicates that emotional stressors, such as arguments or conflicts, may impact the client's sleep patterns. The nurse may want to explore how often these conflicts occur and how they affect the client's ability to fall asleep or stay asleep. Additionally, the nurse may inquire about coping strategies or interventions that the client and their partner use to address conflicts and minimize their impact on sleep.
C. This statement suggests that the client experiences deep or heavy sleep, which may or may not be problematic depending on the context. While deep sleep can be indicative of good sleep quality, it may also raise concerns about the client's ability to awaken in the event of an emergency or the presence of a sleep disorder such as hypersomnia. The nurse may want to inquire further about the client's overall sleep duration, sleep latency, and any difficulties with waking up in the morning.
D. This statement suggests that the client may experience sleep talking, which is a common sleep phenomenon. While sleep talking itself is typically benign, it may indicate underlying sleep disturbances such as sleep fragmentation or abnormal sleep cycles. The nurse may want to ask additional questions to assess the frequency and content of the sleep talking, as well as any potential impacts on the client's sleep quality or daytime functioning.

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Correct Answer is ["A","C","E"]

Explanation

A. Assessing family members for potential poor bereavement outcomes, such as complicated grief or unresolved issues, allows the nurse to provide appropriate support and interventions. This may involve identifying risk factors, offering counseling or referrals to support services, and providing emotional support to family members as needed.

C. Assessing the understanding of the dying process among family members helps the nurse identify their informational needs, address misconceptions, and provide education and support accordingly. Clear communication and open dialogue can help alleviate anxiety and uncertainty and empower family members to participate actively in the care of their loved one.

E. Respecting and supporting the client's religious and cultural beliefs and practices is essential in providing culturally competent care. This may involve collaborating with spiritual or religious leaders, facilitating rituals or ceremonies, providing appropriate accommodations, and honoring the client's preferences regarding end-of-life care and decision-making.

B. Encouraging frequent meals may not be appropriate during the dying process, as the client's appetite and ability to eat may be significantly diminished. Instead, the focus should be on providing comfort measures, maintaining oral hygiene, and offering small, manageable amounts of food or fluids based on the client's preferences and comfort level.

D. Urging the family to limit their time with the client is contrary to supporting them during the dying process. Family presence and involvement are essential for providing emotional support, companionship, and comfort to the client. Encouraging meaningful interactions and opportunities for sharing memories and expressions of love can promote a sense of connection and closure for both the client and their family.

A. higher than the piggyback medication. B. lower than the piggyback medication. C. at the same height as the the piggyback bag. D. lower than the IV insertion site.

Correct Answer is A

Explanation

A. Positioning the primary IV solution bag higher than the piggyback medication bag creates a pressure gradient, allowing the primary solution to infuse first. Once the primary solution has finished, the secondary piggyback medication automatically starts infusing. This setup ensures that the primary solution is fully infused before the piggyback medication begins.
B. Placing the primary IV solution bag lower than the piggyback medication bag is not the standard practice. This setup would create a pressure gradient that could result in the piggyback medication infusing before the primary solution, which is not desirable. It could lead to incomplete infusion of the primary solution and compromise the effectiveness of the treatment.
C. Positioning the primary IV solution bag at the same height as the piggyback bag does not create a pressure gradient for sequential infusion. As a result, both solutions would flow at the same rate, and it would be challenging to control the order of infusion. This setup is not appropriate for administering IV antibiotics via piggyback because it does not ensure the proper sequence of infusion.
D. The height of the IV solution relative to the insertion site is essential for proper infusion and preventing complications such as infiltration or phlebitis. Ideally, the IV solution should be hung at a height that allows for a gentle flow of fluid into the vein without causing excessive pressure or backflow. Placing the IV solution lower than the insertion site helps facilitate gravity-assisted flow into the vein.

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The nurse is assessing a client's sleep patterns. Which statement made by the client would require additional questioning by the nurse? "My partner tells me that:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the dying process. How can the nurse best support the client and their family? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","E"]

Explanation

A client requires an IV antibiotic piggyback. The nurse understands that the primary IV solution with gravity flow tubing needs to be hung:

Correct Answer is A

Explanation

The nurse is teaching a client about management of heart disease. What strategy can the nurse implement to promote learning in the affective domain?

A nurse discovers that the physician has prescribed a higher than recommended dose of a medication for a client. Which is the most appropriate action for the nurse to take?

The nurse recognizes that which behavior would not be considered a sign of grief resolution in a client whose partner died a year ago? The client

The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?

The nurse knows the fecal output will be more solid from a stoma created from which area of the bowel?

The client experiencing abdominal distention and severe vomiting has just had a nasogastric (NG) tube inserted. When teaching this client, which rationale for the use of the NG tube should the nurse include?