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 C

Explanation

C. Respect for the deceased person's cultural and religious beliefs is crucial. Care should be provided in a manner that aligns with their customs and traditions. This may involve specific rituals, prayers, or practices depending on the individual's cultural or religious background.
A. While completing documentation on the death certificate is important for legal and administrative purposes, it is not the priority during post-mortem care.
B. While it's essential to handle the deceased person's belongings with care and ensure they are returned to the family, this task can typically wait until after the immediate post-mortem care has been provided. It's not the priority during the initial stages of post-mortem care.
D. This task is important, but it should be carried out after the completion of post-mortem care. Once the deceased person has been respectfully prepared, the next step is to transfer them to the morgue or the designated location.

A. Allow the formula to reach room temperature B. Label feeding container with client's name and date/time hung C. Aspirate stomach contents and check pH for tube placement D. Assess residual volume

Correct Answer is C

Explanation

C. This is a critical initial step before administering enteral feedings. Aspirating stomach contents helps confirm the placement of the nasogastric tube in the stomach rather than the respiratory tract. Checking the pH of the aspirate can further confirm gastric placement, as gastric fluid typically has an acidic pH (usually less than 5). This step ensures that the feeding will be delivered to the correct location, minimizing the risk of aspiration.
A. While it's important for the formula to be at an appropriate temperature for administration to prevent discomfort or complications such as cramping, this is not typically the first action to take. It can be done concurrently with other preparatory steps.
B. Proper labeling of the feeding container is essential for patient safety and adherence to institutional policies. However, this is not the first action to be completed. It's usually done after preparing the feeding and confirming the tube placement.
D. Assessing residual volume involves checking for any residual contents in the stomach from previous feedings. This step helps determine how much of the previous feeding remains in the stomach and whether it's safe to administer the next feeding. However, it typically follows confirming tube placement, as it's essential to know the tube is in the correct position before assessing residual volume.

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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

The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

Correct Answer is C

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?

Correct Answer is C

Explanation

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