A nurse is assessing a client who has chronic insomnia. Which question would address the highest safety priority for the client?

When did you begin to have trouble sleeping?

Are there any specific factors that you think are affecting your ability to sleep?

Do you have difficulty staying awake when you are driving?

Can you describe your bedtime routine to me?

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Asking “When did you begin to have trouble sleeping?” is important for understanding the onset and duration of the client’s insomnia. However, it does not directly address immediate safety concerns. Chronic insomnia can lead to significant daytime impairment, but the question about the onset of sleep troubles does not identify specific safety risks.

Choice B Reason:

Inquiring about specific factors affecting the client’s ability to sleep can help identify potential causes of insomnia, such as stress, environmental factors, or medical conditions. While this information is valuable for treatment planning, it does not directly address immediate safety concerns.

Choice C Reason:

Asking “Do you have difficulty staying awake when you are driving?” addresses the highest safety priority. Chronic insomnia can lead to excessive daytime sleepiness, which significantly increases the risk of accidents, especially while driving. Identifying whether the client is at risk of falling asleep during potentially dangerous activities is crucial for immediate safety.

Choice D Reason:

Understanding the client’s bedtime routine can provide insights into their sleep hygiene and habits, which are important for managing insomnia. However, this question does not directly address immediate safety concerns related to daytime functioning and the risk of accidents.

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Correct Answer is ["2"]

Explanation

To determine the number of tablets per dose, follow these steps:

Calculate the total daily dose in milligrams (mg):
- 2 grams (g) = 2000 milligrams (mg)
Divide the total daily dose by the number of doses per day:
- 2000 mg/day ÷ 2 doses/day = 1000 mg/dose
Determine the number of tablets per dose:
- Each tablet is 500 mg.
- 1000 mg/dose ÷ 500 mg/tablet = 2 tablets/dose

Therefore, the nurse should administer 2 tablets of 500 mg amoxicillin with each dose.

A. Cover B. Clean C. Debride D. Leave alone

Correct Answer is C

Explanation

Choice A reason: Cover

Covering a wound with slough is not an appropriate intervention. Slough is a type of necrotic tissue that can impede the healing process by providing a medium for bacterial growth and preventing the formation of healthy granulation tissue. Simply covering the wound without addressing the slough can lead to infection and delayed healing.

Choice B reason: Clean

Cleaning the wound is a necessary step in wound care, but it is not sufficient on its own to address the presence of slough. While cleaning can help reduce the bacterial load and remove some debris, it does not effectively remove the slough itself. Slough often requires more targeted interventions such as debridement to be effectively managed.

Choice C reason: Debride

Debridement is the most appropriate intervention for a wound with slough. Debridement involves the removal of necrotic tissue, including slough, to promote a clean wound bed and facilitate the healing process. There are several methods of debridement, including autolytic, enzymatic, mechanical, and surgical, each with its own indications and benefits. Removing the slough allows for better assessment of the wound and promotes the formation of healthy granulation tissue.

Choice D reason: Leave Alone

Leaving a wound with slough alone is not advisable. Slough can harbor bacteria and impede the healing process, leading to chronic wounds and potential infection. Without intervention, the wound is unlikely to progress through the normal stages of healing.

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A nurse is assessing a client who has chronic insomnia. Which question would address the highest safety priority for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["2"]

Explanation

A nurse is assessing a client’s wound and notes there is slough present. What would be an appropriate intervention for this wound?

Correct Answer is C

Explanation

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

A nurse is providing education about when health care referrals would be appropriate. When should a healthcare provider order a referral?

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