A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

"Perform muscle relaxation before bedtime.”

"Exercise vigorously 1 hour prior to going to bed.”

"Drink a cup of hot chocolate at bedtime.”

"Change the time you go to sleep each day.”

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Perform muscle relaxation before bedtime."

Choice A rationale:

Suggesting to the client to "Perform muscle relaxation before bedtime" is a helpful recommendation. Muscle relaxation techniques, such as progressive muscle relaxation or deep breathing exercises, can help calm the body and mind, making it easier to fall asleep.

Choice B rationale:

Advising the client to "Exercise vigorously 1 hour prior to going to bed" is not recommended. Vigorous exercise close to bedtime can actually stimulate the body and make it harder to fall asleep. Gentle, non-strenuous activities are more suitable before bedtime.

Choice C rationale:

Recommending the client to "Drink a cup of hot chocolate at bedtime" is not ideal. Hot chocolate contains caffeine, which is a stimulant that can interfere with sleep. It's better to avoid caffeine-containing beverages close to bedtime.

Choice D rationale:

Suggesting the client to "Change the time you go to sleep each day" disrupts the body's internal clock and sleep-wake cycle. Maintaining a consistent sleep schedule, even on weekends, helps regulate the body's natural sleep patterns.

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Correct Answer is C

Explanation

The correct answer is choice C. Headache.

Choice A rationale:

Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.

Choice B rationale:

Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.

Choice C rationale:

Headache is a potential adverse effect of a lumbar puncture. This is caused by the leakage of cerebrospinal fluid (CSF) through the puncture site, leading to a decrease in CSF pressure. This drop in pressure can cause a headache, particularly when the client sits or stands up. The headache is often described as severe and may be accompanied by neck pain and sensitivity to light. It usually resolves within a few days but can be managed with pain relief medications and plenty of fluids.

Choice D rationale:

Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.

A. A piston syringe. B. Barrier ointment. C. Chilled irrigation solution. D. Sterile cotton balls.

Correct Answer is A

Explanation

Choice A rationale:

The correct answer. A piston syringe is used for wound irrigation to deliver a controlled and directed flow of fluid to clean the wound. It helps remove debris and promote healing. This choice aligns with wound irrigation best practices.

Choice B rationale:

Barrier ointment is not typically used for wound irrigation. Its purpose is to protect intact skin from moisture, friction, and other irritants, rather than to clean wounds.

Choice C rationale:

Chilled irrigation solution is not commonly used for wound irrigation. Room temperature or warm sterile saline is usually recommended for wound cleansing as cold solutions can cause discomfort and vasoconstriction.

Choice D rationale:

Sterile cotton balls are not used for wound irrigation. They may leave fibers in the wound, potentially leading to infection. Wound irrigation is usually performed using sterile syringes, solutions, and appropriate irrigation devices.

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A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Correct Answer is C

Explanation

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use?

Correct Answer is A

Explanation

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities?

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

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