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 B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

A. Each element has a range from one to five points. B. The higher the score, the higher the pressure injury risk. C. The scale measures six elements. D. The client's age is part of the measurement.

Correct Answer is C

Explanation

The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.

Option a is incorrect because each element has a range from one to four points.

Option b is incorrect because the lower the score, the higher the pressure injury risk.

Option d is incorrect because the client's age is not part of the measurement.

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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 is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?

Correct Answer is B

Explanation

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

Correct Answer is C

Explanation

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