A nurse is caring for a client who reports difficulty falling asleep. Which of the following
recommendations should the nurse make?
Drink a cup of hot coca before bedtime
Maintain a consistent time to wake up each day
Exercise 1 hour before going to bed
Watch a television program in bed before going to sleep - (correct Answer) - Maintain a consistent time
to wake up each day
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should
the nurse implement for this client?
Have the client wear a mask when receiving visitors
Wear a gown when caring for a client
Assign a client to a room with negative-pressure airflow exchange
Limit a client's time with visitors to more than 30 min per day - (correct Answer) - Wear a gown when
caring for a client
A nurse is assessing a client who reports increased pain following physical therapy. Which of the
following questions should the nurse ask when assessing the quality of the client's pain?
Is your pain constant or intermittent?
What would you rate your pain on the scale of 0 to 10?
Does the pain radiate?
Is your pain sharp or dull? - (correct Answer) - Is your pain sharp or dull?
A nurse in a surgical suit documentation on a client's medical record that they have a latex allergy. In
preparation for the client's procedure, which of the following precautions should the nurse take?
Ensure sterilization of nondisposable items with ethylene oxide
Wrap monitoring cords with stockinette and tap them in place
Cleanse latex ports on IV tubing with chlorhexidine before injecting medication
Wear hypoallergenic latex gloves that contain powder - (correct Answer) - Wrap monitoring cords with
stockinette and tap them in place
Many monitor devices and cords contain latex. The nurse should prevent any contact of these cords and
devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and
using nonlatex tape to secure them
, The nurse should use a stopcock for injecting medication. Cleansing a latex item will not remove the
latex protein
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should
the nurse expect?
Numbness of the extremities
Bradycardia
Positive Chvostek's sign
Abdominal cramping - (correct Answer) - Abdominal cramping
Normal range Na+: 135-145 mEq/L
Hyponatremia - abdominal cramping, weakness, confusion, lethargy, headache, and nausea
Tachycardia is manifestation of hyponatremia along with hypovolemia.
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage.
Which of the following types of transmission precautions should the nurse initiate?
Protective environment
Airborne precautions
Droplet precautions
Contact precautions - (correct Answer) - Contact precautions
Major wound infections require contact precautions, which means the nurse should admit the client to a
private room. All caregivers should wear a gown and gloves during direct contact with this client
Clients who have a compromised immune system require a protective environment
Airborne precautions are a requirement for a client who have infections that spread via droplet nuclei
that are larger than 5 microns in diameter: tuberculosis and measles
Droplet precautions are a requirement for a client who have infections that spread via droplet nuclei that
are larger than 5 microns in diameter: rubella, meningococcal pneumonia, streptococcal pharyngitis
A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by
the client should indicate to the nurse that the client is ready to hear information regarding palliative
care?