A nurse is providing teaching about measures to promote sleep with a client who has Insomnia. Which of the following client statements Indicates an understanding of the teaching?

"I can exercise as late as 1 hour before bedtime."

"I should reduce my fluid intake 2 hours before bedtime."

"I should take a 1 hour nap each day.

"I can eat a large meal as late as 1 hour before bedtime."

Answer and Explanation

The Correct Answer is B

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

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Correct Answer is C

Explanation

A. Remove a piece of the new dressing that falls 5 cm (2 in) from the edge of the sterile field during the dressing change. Incorrect, as the item is contaminated and should not be used.

B. Begin the dressing change by applying sterile gloves and removing the existing dressing. The old dressing should be removed with clean gloves before donning sterile gloves.

C. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray. Any contamination of the sterile field requires a complete restart to maintain sterility.

D. Place the existing dressing on the outermost portion of the sterile field and discard it when the dressing change is finished. Contaminates the sterile field; old dressings should be disposed of immediately.

A. Document shiny, taut skin as an expected finding. B. Perform palpation after auscultation. C. Listen for 1 min before documenting absent bowel sounds. D. Perform auscultation immediately after the client has consumed a meal.

Correct Answer is B

Explanation

A. Document shiny, taut skin as an expected finding. Shiny, taut skin may indicate ascites or fluid retention, which are abnormal findings.

B. Perform palpation after auscultation. Palpation should always follow auscultation to avoid altering bowel sounds.

C. Listen for 1 min before documenting absent bowel sounds. Bowel sounds are considered absent only after listening for at least 5 minutes in each quadrant.

D. Perform auscultation immediately after the client has consumed a meal. Post-meal auscultation may result in altered bowel sounds, making the assessment unreliable.

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A nurse is providing teaching about measures to promote sleep with a client who has Insomnia. Which of the following client statements Indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

Correct Answer is C

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Correct Answer is B

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