A nurse is caring for a client in an outpatient clinic

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep

Bedtime

Use of chronic devices

Evening meal

Medication

Caffeine use

Exercise schedule

Answer and Explanation

Correct Answer : C,F

A. Bedtime: The client’s bedtime of 2330 has remained unchanged despite the shift in work hours, providing some stability to the circadian rhythm. A consistent bedtime typically supports sleep regulation rather than disrupting it. Although the new routine may affect sleep pressure, the bedtime is not the primary contributor to the new difficulties falling asleep.

B. Use of chronic devices: The client turns off their phone at 2230, limiting blue-light exposure well before bedtime. There is no indication of prolonged screen use or other electronic stimulation that would interfere with melatonin release. With the device turned off an hour before bed, this factor is unlikely to be influencing the client’s disrupted sleep.

C. Evening meal: The client now eats dinner late in the evening after a 1200–2000 work shift, placing the meal close to their 2330 bedtime. Eating late can increase gastrointestinal activity and delay the body’s transition into restful sleep, contributing to both difficulty falling asleep and nighttime awakenings.

D. Medication: The client’s medications ethinyl estradiol/desogestrel and ferrous sulphate have remained consistent for months without changes in timing or dosage. These medications are not known to disrupt sleep when taken as prescribed and do not coincide with the recent onset of nighttime symptoms.

E. Caffeine use: Although the client now drinks 2 to 3 cups of coffee, it is consumed early in the morning and remains outside the usual window in which caffeine impacts nighttime sleep. Morning intake allows adequate time for caffeine metabolism before bedtime. The timing makes it a less significant factor in the client’s difficulties initiating and maintaining sleep.

F. Exercise schedule: The client exercises immediately after a shift that ends at 2000, pushing vigorous activity close to bedtime. Late-evening exercise can increase sympathetic activity and core body temperature, which can interfere with the body’s ability to relax and initiate sleep.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Inform the client that they will need to fast 4hr prior to the procedure: Fasting is generally not required for a thoracentesis unless moderate sedation or general anesthesia is planned. Routine thoracentesis is often performed with local anesthesia only, so strict fasting is unnecessary.

B. Explain that a needle will be inserted in the pleural space to withdraw fluid: Providing a clear explanation of the procedure helps reduce anxiety and ensures the client understands what to expect. Educating about needle insertion and fluid removal is essential for informed cooperation.

C. Obtain informed consent from the client: Informed consent is required for thoracentesis because it is an invasive procedure with risks such as pneumothorax, bleeding, and infection. The nurse must verify that consent is signed before proceeding.

D. Inform the client they will be sedated for the procedure: Many thoracenteses use local anesthesia with minimal sedation. Informing the client about sedation ensures understanding of the procedure and preparation for comfort measures, especially if moderate sedation is used.

E. Place the client in an upright position leaning over a bedside table: Proper positioning facilitates optimal access to the pleural space and improves patient safety and comfort. This upright posture with arms resting on a table is standard practice for thoracentesis.

F. Administer a cough suppressant to the client prior to the procedure: Suppressing cough is not routinely indicated before thoracentesis. The client may need to cough or take deep breaths during or after the procedure to prevent complications, so routine cough suppression is not recommended.

A. Cleansing the insertion site daily B. Covering the insertion site with a transparent dressing C. Administering supplemental opioids as needed D. Replacing the infusion tubing every 72 hr

Correct Answer is B

Explanation

A. Cleansing the insertion site daily: Frequent cleansing of an epidural insertion site is not recommended because excessive manipulation increases the risk of infection. Standard practice is to keep the site clean and dry, assessing it regularly without daily cleaning unless contamination occurs.

B. Covering the insertion site with a transparent dressing: Using a sterile, transparent dressing allows continuous visualization of the insertion site for early signs of infection, leakage, or inflammation. It protects the site while permitting ongoing assessment, which is essential for clients receiving epidural analgesia.

C. Administering supplemental opioids as needed: Supplemental opioids should be used cautiously in clients with epidural analgesia because they can increase the risk of respiratory depression and sedation. Pain management should primarily rely on the epidural infusion and follow prescribed protocols rather than routine PRN systemic opioids.

D. Replacing the infusion tubing every 72 hr: Epidural infusion tubing typically should be replaced according to institutional protocol, often every 24 hours, not 72 hours, to reduce the risk of infection. Extending tubing changes beyond recommended intervals increases the likelihood of contamination and catheter-related complications.

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A nurse is caring for a client in an outpatient clinic Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the female client's medical record. The nurse is preparing the client for a thoracentesis. Select the 4 actions that the nurse should take.

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is caring for a client who is receiving a controlled epidural analgesia infusion. Which of the following nursing actions is appropriate?

Correct Answer is B

Explanation

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A nurse is caring for a client in an outpatient clinic

Exhibits

Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep