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 can increase gastric activity and cause indigestion, which interferes with the body’s ability to transition into a restful sleep state.

💎 Allowing 3 hours before sleep gives the body time to complete most digestive processes, reducing discomfort and nocturnal awakenings.

💎 This practice supports circadian rhythm regulation by avoiding metabolic stimulation at a time when the body should be winding down.

💎 Gastroesophageal reflux symptoms are also minimized when meals are consumed earlier, promoting a more restful sleep.

💎 Teaching the client healthy sleep hygiene like meal timing is a key non-pharmacological intervention for insomnia management.

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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 emergencies involving minors, verbal telephone consent from a parent or legal guardian is legally acceptable when written consent cannot be immediately obtained.

💎 The grandmother can sign the consent only after the parents give explicit permission, ensuring legal and ethical adherence to consent regulations.

💎 This process protects the minor’s rights while ensuring necessary emergency surgical interventions are not delayed.

💎 Telephone consent must be documented thoroughly in the medical record, including who provided consent and at what time.

💎 This aligns with hospital policy and maintains legal protection for the healthcare team and the facility.

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Answer 3

Correct Answers:

Close the newborn's eyes before applying the mask.

Rationale :

💎 Phototherapy light used for hyperbilirubinemia can damage the retina, making eye protection essential.

💎 The eyes should be closed gently before placing the mask to prevent corneal abrasion and ensure the mask sits securely.

💎 The mask should be checked frequently for proper alignment to avoid pressure injuries or displacement.

💎 Eye exposure to phototherapy can lead to retinal damage, making this a critical safety intervention.

💎 Phototherapy care also involves frequent repositioning and hydration, but eye protection remains a top priority.

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Answer 4

Correct Answers:

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

Rationale :

♦️Petrolatum prevents the diaper from sticking to the healing circumcision site, reducing pain and tissue trauma during diaper changes.

♦️ Application promotes moist wound healing, which is essential for faster tissue recovery.

♦️Gomco clamp sites typically heal within 5–7 days, and petrolatum helps maintain a protective barrier against friction and moisture.

♦️ The presence of yellowish exudate is normal during healing and should not be removed as it indicates proper healing.

♦️ Consistent application of petrolatum supports comfort and infection prevention in the circumcised infant.

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Answer 5

Correct Answers:

A client who has a closed head injury and is vomiting.

Rationale :

🟠 Vomiting after a head injury is a sign of possible increased intracranial pressure (ICP) and must be addressed immediately.

🟠 Delays in intervention can lead to brain herniation or neurological deterioration.

🟠 This client requires immediate neurological assessment, including Glasgow Coma Scale monitoring.

🟠 Rapid evaluation is crucial to prevent secondary brain injury and ensure timely interventions such as neuroimaging or ICP management.

🟠 Prioritization follows the ABC and neurological priority framework, where potential life-threatening conditions are managed first.

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Answer 6

Correct Answers:

Weeping skin surfaces

Rationale :

🟣 Stevens-Johnson syndrome (SJS) is a severe mucocutaneous reaction often triggered by medications, leading to epidermal detachment and weeping lesions.

🟣 The condition involves painful, oozing skin surfaces that resemble second-degree burns.

🟣 Prompt identification is critical to prevent complications like infection and fluid-electrolyte imbalances.

🟣 Supportive care includes wound care, fluid replacement, and infection control.

🟣 Recognizing weeping skin as a hallmark sign ensures early intervention and transfer to a burn or ICU unit if needed.

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Answer 7

Correct Answers:

When the client has communicated an intention to harm someone.

Rationale :

⏺️ Confidentiality can be breached legally and ethically when a client poses a threat to themselves or others.

⏺️ Duty to warn is a legal obligation under the Tarasoff ruling, requiring healthcare providers to protect potential victims.

⏺️ Reporting ensures safety of the public while still maintaining confidentiality for non-threatening information.

⏺️ Documentation must include the specific threat, intended victim, and persons notified.

⏺️ Nurses are ethically bound to prioritize safety over confidentiality in such circumstances.

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Answer 8

Correct Answers:

10

Rationale :

✏️Available: 25,000 units/250 mL

100 units/mL

✏️ Order: 1,000 units/hr

mL/hr=1,000 units/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, and macrolide antibiotics like azithromycin are the first-line treatment.

🟢 Early administration reduces bacterial load and transmission risk.

🟢 Supportive care may include humidified oxygen and frequent suctioning, but antibiotic therapy is key to limiting disease severity.

🟢 Contact and droplet precautions are implemented to prevent nosocomial spread, but the priority treatment is antimicrobial therapy.

🟢 Prompt antibiotic therapy shortens the infectious period, protecting vulnerable populations such as infants.

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Answer 10

Correct Answers:

Omeprazole

Rationale :

🟠 Long-term use of proton pump inhibitors (PPIs) like omeprazole is associated with decreased calcium absorption, contributing to osteoporosis.

🟠 PPIs reduce gastric acid secretion, which is necessary for calcium carbonate dissolution and absorption.

🟠 Chronic hypochlorhydria can also impair magnesium and vitamin B12 absorption, further impacting bone health.

🟠Nurses should teach clients about bone health strategies, including calcium and vitamin D supplementation.

🟠 Awareness of this adverse effect guides regular monitoring of bone density in long-term PPI users.

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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?