During a sleep history evaluation, which statement by the client requires further follow-up?

I usually fall asleep after about 15 minutes.

I wake up to urinate once each night.

I often wake up feeling tired in the morning.

I have a regular nighttime routine.

Answer and Explanation

The Correct Answer is C

This statement requires further follow-up because it indicates that the client may have poor sleep quality or quantity, which can affect their health and well-being. According to, the main components of the sleep history include defining the specific sleep problem, assessing the disorder’s clinical course, differentiating between sleep disorders, evaluating the sleep-wakefulness patterns, questioning the bed partner, and obtaining a family history of sleep disorders.

Choice A is wrong because falling asleep after about 15 minutes is normal and indicates good sleep hygiene.

Choice B is wrong because waking up to urinate once each night is not uncommon in older adults and does not necessarily disrupt their sleep continuity.

Choice D is wrong because having a regular nighttime routine is beneficial for promoting relaxation and preparing for sleep.

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Correct Answer is C

Explanation

This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.

Some additional information for the response are:

Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.

Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.

Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.

Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).

A. Apply warm soaks to reduce the inflammation. B. Notify the health care provider immediately of the infection. C. Place the client on contact (wound) precautions. D. Document the findings and continue to monitor the wound.

Correct Answer is D

Explanation

. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can

cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.

These are normal signs of wound healing and do not indicate infection or complications.

Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.

Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.

Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.

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During a sleep history evaluation, which statement by the client requires further follow-up?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

Correct Answer is C

Explanation

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

Correct Answer is D

Explanation

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