Question

A nurse is teaching about methods to promote sleep to a client who has insomnia. Which of the following statements should the nurse make?

Answer 1

Correct Answers:

"Avoid eating heavy meals 3 hours before bedtime."

Rationale :

💤Heavy meals close to bedtime increase gastrointestinal activity and can cause indigestion or reflux, making it harder to fall asleep.

💤The body’s digestive workload keeps metabolism active, delaying the transition to restorative sleep.

💤Encouraging a light snack (if hungry) rather than a full meal promotes comfort and relaxation.

💤Other sleep hygiene measures include maintaining a consistent bedtime, avoiding caffeine and electronics, and creating a calm sleep environment.

💤Teaching should also emphasize relaxation techniques such as deep breathing or reading.

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Answer 2

Correct Answers:

"If his parents agree by phone that you may give consent, we'll need you to sign the form."

Rationale :

🩺In an emergency for a minor (under 18), verbal or telephone consent from the legal guardian or parent is acceptable, witnessed by two health care staff.

🩺If parents authorize the grandmother to sign, she can legally do so on their behalf.

🩺This ensures timely treatment while maintaining informed consent and legal compliance.

🩺If no guardian is reachable and the situation is life-threatening, emergency consent may be implied by law.

🩺Clear documentation of the phone authorization and signatures of witnesses is essential for legal protection.

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Answer 3

Correct Answers:

Close the newborn's eyes before applying the mask.

Rationale :

✔️Phototherapy uses high-intensity blue light to break down unconjugated bilirubin into a water-soluble form for excretion, but this light can cause retinal damage if the eyes are not protected.

✔️Before starting therapy, the nurse must gently close the newborn’s eyes and place an opaque eye mask that fits snugly without obstructing the nose.

✔️The mask should remain in place during exposure and be removed periodically for eye cleansing and assessment of irritation or discharge.

✔️Proper protection ensures that visual development is not impaired while allowing uninterrupted bilirubin reduction.

✔️Eye care and frequent monitoring of hydration and temperature are essential parts of safe phototherapy.

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Answer 4

Correct Answers:

"l will apply petrolatum to his penis with each diaper change."

Rationale :

🔹After a Gomco clamp circumcision, the penile glans is exposed and can easily adhere to the diaper, causing pain, bleeding, or tissue trauma.

🔹Applying petrolatum jelly (Vaseline) with each diaper change acts as a moisture barrier, preventing friction and protecting the healing tissue.

🔹The area should be kept clean and dry, and the diaper placed loosely to promote airflow and comfort.

🔹A yellowish exudate or crust forms naturally within 24–48 hours and indicates normal healing, not infection.

🔹Full healing typically occurs within 7 to 10 days, during which gentle care and monitoring for signs of infection are essential.

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Answer 5

Correct Answers:

A client who has a closed head injury and is vomiting

Rationale :

⚠️Vomiting following a head injury is a key warning sign of increased intracranial pressure (ICP) or a potential intracranial bleed.

⚠️Rising ICP compromises cerebral perfusion, leading to brain herniation and neurological decline if untreated.

⚠️This client is the highest priority based on the ABC and neurological assessment framework, as airway and cerebral function are at risk.

⚠️The nurse should immediately assess neurological status, elevate the head of bed 30 degrees, and notify the provider.

⚠️ Early intervention may prevent permanent brain injury or death.

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Answer 6

Correct Answers:

Weeping skin surfaces

Rationale :

💠Stevens–Johnson syndrome (SJS) is a rare, severe drug-induced hypersensitivity reaction involving the skin and mucous membranes.

💠It begins with flu-like symptoms and progresses to painful, erythematous lesions that blister and slough off, leaving weeping, denuded surfaces similar to burns.

💠These open areas are highly susceptible to infection, dehydration, and electrolyte loss, necessitating sterile handling and wound care.

💠Offending medications—often sulfa drugs, anticonvulsants, or antibiotics—must be immediately discontinued.

💠Supportive management includes fluid resuscitation, pain control, and infection prevention in a burn or intensive care unit.

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Answer 7

Correct Answers:

When the client has communicated an intention to harm someone

Rationale :

⚖️The nurse’s duty to protect overrides confidentiality when a client expresses a specific and credible threat of violence toward another person.

⚖️Ethical and legal standards, such as the Tarasoff ruling, require reporting to authorities or the intended victim to prevent harm.

⚖️Documentation of the statement, notification of the provider, supervisor, and law enforcement, and implementation of safety measures are necessary.

⚖️Confidentiality remains essential in all other cases unless there is risk to life or safety.

⚖️This balance ensures ethical integrity while prioritizing public protection.

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Answer 8

Correct Answers:

10

Rationale :

✍️Formula:

♦️(Prescribed units ÷ Concentration) = mL/hr

✍️1,000 units/hr ÷ 100 units/mL

✔️10 mL/hr.

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Answer 9

Correct Answers:

Administer azithromycin.

Rationale :

🩺Pertussis (whooping cough) is caused by Bordetella pertussis, a bacterial respiratory infection that requires macrolide antibiotics such as azithromycin for treatment.

🩺Early antibiotic therapy reduces both disease severity and transmission to others, making it a public health priority.

🩺Droplet precautions are also initiated to prevent spread through respiratory secretions.

🩺Symptomatic management includes hydration, rest, and airway monitoring due to risk of apnea in infants.

🩺Family members and close contacts may receive prophylactic antibiotics as a preventive measure.

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Answer 10

Correct Answers:

Omeprazole

Rationale :

🦴Omeprazole, a proton pump inhibitor (PPI), suppresses gastric acid secretion by inhibiting the H⁺/K⁺ ATPase enzyme system in parietal cells.

🦴Chronic acid suppression decreases calcium and magnesium absorption, contributing to bone demineralization and osteoporosis with long-term use.

🦴Clients on prolonged PPI therapy are at risk for hip, wrist, and spine fractures.

🦴Nursing interventions include encouraging dietary calcium and vitamin D, promoting weight-bearing exercise, and periodic bone density screening.

🦴Consideration may be given to switching to H₂ blockers or using the lowest effective PPI dose.

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QLexNursing

1 :
A nurse is teaching about methods to promote sleep to a client who has insomnia. Which of the following statements should the nurse make?

2 :
An emergency department nurse is admitting a 16-year-old client who has acute abdominal pain and is accompanied by his grandmother. The client requires an emergency appendectomy. Which of the following statements should the nurse make to the grandmother?

3 :
A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following actions should the nurse take?

4 :
A nurse is providing discharge teaching to a client who is 3 days postpartum about her infant's circumcision using a Gomco clamp. Which of the following statements by the client indicates an understanding of the teaching?

5 :
A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to see first?

6 :
A nurse is assessing a client who has developed Stevens-Johnson syndrome. Which of the following manifestations should the nurse expect?

7 :
A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

9 :
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should Identify that osteoporosis is an adverse effect of which of the following medications?

QLexNursing

1 : A nurse is teaching about methods to promote sleep to a client who has insomnia. Which of the following statements should the nurse make?

2 : An emergency department nurse is admitting a 16-year-old client who has acute abdominal pain and is accompanied by his grandmother. The client requires an emergency appendectomy. Which of the following statements should the nurse make to the grandmother?

3 : A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following actions should the nurse take?

4 : A nurse is providing discharge teaching to a client who is 3 days postpartum about her infant's circumcision using a Gomco clamp. Which of the following statements by the client indicates an understanding of the teaching?

5 : A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to see first?

6 : A nurse is assessing a client who has developed Stevens-Johnson syndrome. Which of the following manifestations should the nurse expect?

7 : A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

9 : A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take?

10 : A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should Identify that osteoporosis is an adverse effect of which of the following medications?

1 :
A nurse is teaching about methods to promote sleep to a client who has insomnia. Which of the following statements should the nurse make?

2 :
An emergency department nurse is admitting a 16-year-old client who has acute abdominal pain and is accompanied by his grandmother. The client requires an emergency appendectomy. Which of the following statements should the nurse make to the grandmother?

3 :
A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following actions should the nurse take?

4 :
A nurse is providing discharge teaching to a client who is 3 days postpartum about her infant's circumcision using a Gomco clamp. Which of the following statements by the client indicates an understanding of the teaching?

5 :
A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to see first?

6 :
A nurse is assessing a client who has developed Stevens-Johnson syndrome. Which of the following manifestations should the nurse expect?

7 :
A nurse is teaching a newly licensed nurse about maintaining confidentiality within the nurse-client relationship. The nurse should include that which of the following situations warrants reporting confidential information?

9 :
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who is on long-term therapy for peptic ulcer disease and has a new diagnosis of osteoporosis. The nurse should Identify that osteoporosis is an adverse effect of which of the following medications?