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 B

Explanation

B. Elevating the head of the bed to 30-45 degrees is the recommended position for administering enteral feeding to reduce the risk of aspiration. This semi-upright position helps promote gastric emptying and reduces the likelihood of reflux or regurgitation of the feed into the lungs. It also allows for better tolerance of the feeding and minimizes the risk of complications.
A. Positioning the client on the left side with the knees bent is not typically recommended for enteral feeding. This position may increase the risk of aspiration, especially if the client has impaired swallowing or if there are issues with gastric emptying. It may also not be the most comfortable or practical position for administering enteral feeding.
C. Positioning the client on the right side with a pillow behind the back is not a standard practice for administering enteral feeding. This position may not provide optimal access for administering the feed, and it does not offer the benefits of head elevation to reduce the risk of aspiration.

D. Elevating the head of the bed to only 15 degrees may not provide sufficient upright positioning to reduce the risk of aspiration during enteral feeding. While it is better than lying completely flat, a higher degree of elevation (30-45 degrees) is generally recommended for optimal safety and effectiveness of enteral feeding.

A. pCO2 and pHCO3 and pH are abnormal but the pa02 remains between 80-100 mmHg B. arterial pH & pCO2 are abnormal but the pHCO3 is starting to change C. pCO2, pHCO3 and pH have adjusted in expected range in 72 hours D. arterial pH is between 7.35-7.45 and the pCO2 & pO2 are abnormal

Correct Answer is C

Explanation

C. Full compensation typically occurs within 2 to 3 days (approximately 72 hours) after the onset of an acid-base disturbance. During full compensation, the primary acid-base disorder (e.g., respiratory acidosis or alkalosis, metabolic acidosis or alkalosis) is still present, but the compensatory mechanisms have effectively brought the pH, pCO2, and bicarbonate (pHCO3) levels back towards normal range.
A. Full compensation occurs when both the primary disorder (respiratory or metabolic) and the compensatory mechanism (renal or respiratory) are functioning to return the pH towards normal. In this option, while the pO2 is within the normal range, the pH, pCO2, and bicarbonate (pHCO3) are all abnormal, indicating an ongoing imbalance.
B. Full compensation occurs when all components of the ABG are within or approaching normal range, indicating that the body's compensatory mechanisms have effectively counteracted the primary acid- base disturbance. In this option, the bicarbonate (pHCO3) is mentioned as starting to change, indicating incomplete compensation.
D. While the pH is within the normal range, both the pCO2 and pO2 are abnormal, indicating a primary respiratory disturbance. In the case of full compensation, the pH, pCO2, and bicarbonate (pHCO3) levels would all be within or approaching normal range, indicating that the compensatory mechanisms have effectively counteracted the primary acid-base disturbance.

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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 about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?

Correct Answer is B

Explanation

For an arterial blood gas (ABG) to have full compensation, which of the following statements is correct?

Correct Answer is C

Explanation

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

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

A nurse is administering medications to a client receiving tube feedings through a gastrostomy tube. The correct procedure for administration is to: (SELECT ALL THAT APPLY)

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A client is admitted with a suspected opioid overdose and a respiratory rate of 6 breaths per minute. Which of the following data would the nurse anticipate? (SELECT ALL THAT APPLY)

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