Chapter 17: Comfort, Rest, and Sleep
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A nurse is assisting in the care of a patient who is receiving pain medication by the
epidural route. It is most important to monitor this patient for which adverse drug effects?
a. Constipation
b. Headache
c. Nausea
d. Hypoventilation
ANS: D
Respiratory depression is a potentially dangerous side effect of epidural analgesia, and
a patient receiving this type of pain medication requires frequent monitoring of
respiratory rate.
DIF: Cognitive Level: Comprehension REF: k 604, Steps 31-1
OBJ: Clinical Practice #6 TOP: Epidural Pain Control KEY:
Nursing Process Step: Implementation MSC: NCLEX: Physiological
Integrity: pharmacological therapies
2. A patient with an epidural catheter needs to have the dressing at the insertion site
changed. When cleaning the insertion site with povidone-iodine swabs, the nurse should:
a. use a circular motion working from the insertion site outward.
b. use a circular motion working from the outside to the insertion site.
c. start above the insertion site and swab in a downward motion.
d. start below the insertion site and swab in an upward motion.
ANS: A
Proper aseptic technique includes starting at the center (the insertion site) and working
outward using a circular motion.
DIF: Cognitive Level: Application REF: k 604, Steps 31-1 OBJ:
Clinical Practice #5 TOP: Epidural Catheter KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
3. A nurse is assessing the status of a patient who is sleeping. Which assessment data
indicate that the patient is most likely in stage 3 of nonrapid eye movement (NREM)
sleep?
a. Rapid respirations, rapid heart rate
b. Rapid respirations, slow heart rate
c. Decreased respirations, slow heart rate
d. Decreased respirations, rapid heart rate
ANS: C
Stage 3 of NREM sleep, in which respirations and heart rate slow, is similar to a
coma; it is also called delta sleep or slow-wave sleep because of the high-voltage slow
brain waves that occur.
DIF: Cognitive Level: Comprehension REF: k 604 OBJ: Theory #7
, TOP: Sleep KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: basic care and comfort
4. The nurse recommends that normal sleep patterns can best be acquired by suggesting to
the patient that they:
a. smoke cigarettes.
b. drink wine.
c. take a nap during the day.
d. exercise in the mornings.
ANS: D
Maintaining a regular exercise schedule not too close to bedtime helps a person sleep.
DIF: Cognitive Level: Comprehension REF: k 604 OBJ: Theory #8
TOP: Sleep KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: basic care and comfort
5. A sleeping patient has periodic pauses in breathing, then starts to breathe again. The nurse
recognizes this sleep pattern is consistent with:
a. insomnia.
b. sleep apnea.
c. narcolepsy.
d. excessive NREM sleep.
ANS: B
Sleep apnea is a condition in which the person stops breathing for brief periods during
sleep.
DIF: Cognitive Level: Analysis REF: k 606 OBJ: Theory #8
TOP: Sleep KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: basic care and comfort
6. A patient experiencing pain states that guided imagery has made the pain more
manageable in the past. To assist this patient, the nurse should:
a. find a focal point in the room.
b. bring a newspaper or deck of cards according to patient choice.
c. obtain skin lotion and a towel to give a back rub.
d. read from a script that helps the patient visualize a restful place.
ANS: D
Persons who have difficulty with imagery can be assisted by someone reading a script
to help a patient mentally travel to a favorite spot that is relaxing, soothing, or
peaceful.
DIF: Cognitive Level: Application REF: k 599 OBJ: Theory #4
TOP: Imagery KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity: basic care and
comfort
7. The nurse takes into consideration that when the patient has an order for a patient
controlled analgesia (PCA) the pump will be programmed by the:
a. registered nurse.
b. physician.
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A nurse is assisting in the care of a patient who is receiving pain medication by the
epidural route. It is most important to monitor this patient for which adverse drug effects?
a. Constipation
b. Headache
c. Nausea
d. Hypoventilation
ANS: D
Respiratory depression is a potentially dangerous side effect of epidural analgesia, and
a patient receiving this type of pain medication requires frequent monitoring of
respiratory rate.
DIF: Cognitive Level: Comprehension REF: k 604, Steps 31-1
OBJ: Clinical Practice #6 TOP: Epidural Pain Control KEY:
Nursing Process Step: Implementation MSC: NCLEX: Physiological
Integrity: pharmacological therapies
2. A patient with an epidural catheter needs to have the dressing at the insertion site
changed. When cleaning the insertion site with povidone-iodine swabs, the nurse should:
a. use a circular motion working from the insertion site outward.
b. use a circular motion working from the outside to the insertion site.
c. start above the insertion site and swab in a downward motion.
d. start below the insertion site and swab in an upward motion.
ANS: A
Proper aseptic technique includes starting at the center (the insertion site) and working
outward using a circular motion.
DIF: Cognitive Level: Application REF: k 604, Steps 31-1 OBJ:
Clinical Practice #5 TOP: Epidural Catheter KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
3. A nurse is assessing the status of a patient who is sleeping. Which assessment data
indicate that the patient is most likely in stage 3 of nonrapid eye movement (NREM)
sleep?
a. Rapid respirations, rapid heart rate
b. Rapid respirations, slow heart rate
c. Decreased respirations, slow heart rate
d. Decreased respirations, rapid heart rate
ANS: C
Stage 3 of NREM sleep, in which respirations and heart rate slow, is similar to a
coma; it is also called delta sleep or slow-wave sleep because of the high-voltage slow
brain waves that occur.
DIF: Cognitive Level: Comprehension REF: k 604 OBJ: Theory #7
, TOP: Sleep KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: basic care and comfort
4. The nurse recommends that normal sleep patterns can best be acquired by suggesting to
the patient that they:
a. smoke cigarettes.
b. drink wine.
c. take a nap during the day.
d. exercise in the mornings.
ANS: D
Maintaining a regular exercise schedule not too close to bedtime helps a person sleep.
DIF: Cognitive Level: Comprehension REF: k 604 OBJ: Theory #8
TOP: Sleep KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: basic care and comfort
5. A sleeping patient has periodic pauses in breathing, then starts to breathe again. The nurse
recognizes this sleep pattern is consistent with:
a. insomnia.
b. sleep apnea.
c. narcolepsy.
d. excessive NREM sleep.
ANS: B
Sleep apnea is a condition in which the person stops breathing for brief periods during
sleep.
DIF: Cognitive Level: Analysis REF: k 606 OBJ: Theory #8
TOP: Sleep KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: basic care and comfort
6. A patient experiencing pain states that guided imagery has made the pain more
manageable in the past. To assist this patient, the nurse should:
a. find a focal point in the room.
b. bring a newspaper or deck of cards according to patient choice.
c. obtain skin lotion and a towel to give a back rub.
d. read from a script that helps the patient visualize a restful place.
ANS: D
Persons who have difficulty with imagery can be assisted by someone reading a script
to help a patient mentally travel to a favorite spot that is relaxing, soothing, or
peaceful.
DIF: Cognitive Level: Application REF: k 599 OBJ: Theory #4
TOP: Imagery KEY: Nursing Process Step:
Implementation MSC: NCLEX: Psychosocial Integrity: basic care and
comfort
7. The nurse takes into consideration that when the patient has an order for a patient
controlled analgesia (PCA) the pump will be programmed by the:
a. registered nurse.
b. physician.
