The nurse is caring for a 96-year-old client who has been admitted for treatment of a urinary tract infection. The nurse notices that the client takes two one-hour naps each day, one mid-morning and the other late afternoon. What intervention should the nurse implement?

Encourage the client to try ways to stay awake during the day.

Substitute physical therapy for one of the client's usual nap times.

Ask the physician to order a sleeping pill for the client to take at night.

Do nothing, as no action is necessary in this situation.

Answer and Explanation

The Correct Answer is D

D. It is important to recognize and respect the client's natural sleep patterns, especially considering their age and current health status. Napping during the day can be a normal and beneficial behavior for older adults, helping to replenish energy levels and promote overall well-being. As long as the client's napping does not interfere with their ability to sleep at night or their daily activities, no intervention may be necessary.
A. Encouraging the client to stay awake during the day may not be appropriate, especially considering the client's age and natural sleep patterns. Older adults often experience changes in their sleep-wake cycle, including more frequent napping during the day.
B. Physical activity is important for maintaining mobility and overall health but substituting physical therapy for one of the client's usual nap times may not be feasible or beneficial. The client's need for rest and sleep should be respected, especially if they are experiencing fatigue or illness.
C. Prescribing a sleeping pill for the client may not be appropriate, especially if they are already napping during the day. Sleep medications can have side effects, including drowsiness, confusion, and increased risk of falls, particularly in older adults.

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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. 5% dextrose in 0.25% sodium chloride (D51/4NS) B. 3% sodium chloride (3% NaCl) C. 5% dextrose in water (DSW) D. 0.9% sodium chloride (0.9% NaCl)

Correct Answer is D

Explanation

D. 0.9% sodium chloride (0.9% NaCl): This solution, also known as normal saline, is isotonic and contains the same concentration of sodium as extracellular fluid. It is the most appropriate choice for initial fluid resuscitation in hypovolemia due to severe bleeding because it rapidly expands intravascular volume, replaces sodium losses, and helps restore circulating blood volume.
A. This solution contains dextrose (glucose) and a small amount of sodium chloride. It provides some glucose for energy but has a lower sodium concentration compared to isotonic solutions like normal saline. While it may be used in certain situations, such as to provide maintenance fluids or correct mild dehydration, it is not the first choice for fluid resuscitation in hypovolemia due to severe bleeding because it does not adequately replace lost volume.
B. 3% sodium chloride (3% NaCl): This solution is hypertonic and has a high sodium concentration. It is not typically used for initial fluid resuscitation in hypovolemia due to severe bleeding. Hypertonic saline solutions like 3% NaCl are more commonly used in specific situations such as severe hyponatremia or cerebral edema.
C. 5% dextrose in water (D5W): This solution contains only dextrose and water and is isotonic until the dextrose is metabolized, after which it becomes hypotonic. D5W is not suitable for fluid resuscitation in hypovolemia due to severe bleeding because it does not provide adequate sodium or volume replacement.

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The nurse is caring for a 96-year-old client who has been admitted for treatment of a urinary tract infection. The nurse notices that the client takes two one-hour naps each day, one mid-morning and the other late afternoon. What intervention should the nurse implement?

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

A client is admitted with hypovolemia due to severe bleeding. Which Intravenous fluid does the nurse anticipate using to replace fluid losses?

Correct Answer is D

Explanation

The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Which nursing action should be completed first?

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)

The nurse is caring for a client who is discussing being placed on hospice care. Which statement by the client indicates an understanding of hospice care?

The following arterial blood gas results would demonstrate to the nurse that the client is experiencing which acid-base imbalance? pH 7.31 PaCO2 40, HCO3 18, pa02 92

A client is to receive enteral nutrition. Which information should the nurse provide to the client and family? (SELECT ALL THAT APPLY)

Which statement made by a client experiencing insomnia indicates a need for further education by the nurse? "I

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)