A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

Exercise three times a week in the mornings.

Go to bed at the same time every evening.

Have two glasses of wine every night before bedtime.

Get out of bed when unable to sleep.

Answer and Explanation

The Correct Answer is C

Choice A reason: Regular morning exercise can actually promote better sleep. It helps to regulate the body's clock and can lead to deeper, more restful sleep. However, exercising too close to bedtime may have the opposite effect.

Choice B reason: Going to bed at the same time every evening can help establish a consistent sleep-wake cycle, which is beneficial for people who have insomnia. This regularity can make it easier to fall asleep and wake up naturally.

Choice C reason: Alcohol consumption before bedtime can disrupt sleep patterns. While it may initially help someone fall asleep, it often leads to poorer quality of sleep and can cause awakenings throughout the night.

Choice D reason: If unable to sleep, getting out of bed can be a good strategy. It's part of stimulus control therapy for insomnia, which advises leaving the bed if you can't sleep, so you don't associate the bed with wakefulness

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Correct Answer is D

Explanation

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.

A. Wash the puncture site with soap and water. B. Squeeze as much blood as possible from the puncture site. C. Flush the puncture site with water for 5 minutes. D. Begin postexposure prophylaxis the following day.

Correct Answer is A

Explanation

Choice A reason: Thoroughly cleansing the affected area helps remove potential pathogens. The Centers for Disease Control and Prevention (CDC) advises washing needlestick injuries with soap and water.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: If indicated, postexposure prophylaxis (PEP) should be initiated as soon as possible, ideally within hours of exposure, to maximize its effectiveness. Delaying PEP until the following day is not advisable.

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A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Correct Answer is D

Explanation

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

A client complains of an inability to sleep through the night since admission three days ago. Which of the following factors is most likely to negatively affect the patient's sleep patterns?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following items should the nurse wear?