A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

Decreased judgment

Decreased activity

Increased reﬂexes

Increased auditory alertness

Answer and Explanation

The Correct Answer is A

Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.

Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many diﬀerent conditions, including fatigue or depression. Increased reﬂexes and increased auditory alertness are not commonly associated with sleep deprivation.

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Correct Answer is A

Explanation

When caring for a client who has a tracheostomy, the nurse should secure the tracheostomy ties to allow one finger to fit snugly underneath. This helps ensure that the tracheostomy tube is secure and prevents accidental dislodgement.
b) A cotton tip applicator should not be used to clean inside the inner cannula as it can leave fibers behind
and increase the risk of infection.
c) The skin around the stoma should be cleansed with sterile saline, not normal saline, to reduce the risk of infection.
d) The outer cannula should not be soaked in warm, soapy tap water as this can introduce bacteria and increase the risk of infection.

A. Use a separate, sterile swab for each stroke when cleaning the wound. B. First clean the drain site and then clean the incision. C. Don clean gloves before cleaning the wound. D. Cut a 4 x 4 piece of gauze to place around the drain site.

Correct Answer is A

Explanation

When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.

Option b is incorrect because the nurse should first clean the incision and then clean the drain site.

Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.

Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.

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A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first?

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning an educational conference about informed consent. Which of the following information should the nurse include?

A nurse is caring for a group of clients whose primary languages are diﬀerent from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

A nurse is assessing a client who is receiving continuous IV ﬂuids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing ﬂuid overload?

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)