C HAPTER 31: P AIN , C OMFORT , AND S LEEP
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
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 potentiall y dangerous side effect of
epidural analgesia, and a patient rece iving this t ype of pain medication
requires frequent monitoring of respiratory rate.
DIF: Cognitive Level: Comprehension REF: p. 607
OBJ: Clinical Practice #6 TOP: Epidural Pain Control
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: 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 i nsertion 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 inclu des starting at the center (the insertion
site) and working outward using a circular motion.
DIF: Cognitive Level: Application REF: p. 608 OBJ:
Clinical Practice #5 TOP: Epidural Catheter KEY: Nursing
Process Step: Implementation MSC: NC LEX: Safe,
Effective Care Environment: Safet y 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 likel y in stage 3 of non –
rapid eye movement (NREM) sleep?
a. Rapid respirations, rap id 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: p. 609
OBJ: Theory #7 TOP: Sleep KEY: Nursing Process
Step: Assessment MSC: NC LEX: Physiological Integrit y:
Basic Care and Comfort
4. The nurse recommends that normal sleepatchesp 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: p. 610
OBJ: Theory #8 TOP: Sleep KEY: Nursing Process
Step: Implementation MSC: NC LEX: Physiological
Integrit y: Basic Care and Comfort
5. A sleeping patient has period ic 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
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
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 potentiall y dangerous side effect of
epidural analgesia, and a patient rece iving this t ype of pain medication
requires frequent monitoring of respiratory rate.
DIF: Cognitive Level: Comprehension REF: p. 607
OBJ: Clinical Practice #6 TOP: Epidural Pain Control
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: 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 i nsertion 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 inclu des starting at the center (the insertion
site) and working outward using a circular motion.
DIF: Cognitive Level: Application REF: p. 608 OBJ:
Clinical Practice #5 TOP: Epidural Catheter KEY: Nursing
Process Step: Implementation MSC: NC LEX: Safe,
Effective Care Environment: Safet y 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 likel y in stage 3 of non –
rapid eye movement (NREM) sleep?
a. Rapid respirations, rap id 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: p. 609
OBJ: Theory #7 TOP: Sleep KEY: Nursing Process
Step: Assessment MSC: NC LEX: Physiological Integrit y:
Basic Care and Comfort
4. The nurse recommends that normal sleepatchesp 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: p. 610
OBJ: Theory #8 TOP: Sleep KEY: Nursing Process
Step: Implementation MSC: NC LEX: Physiological
Integrit y: Basic Care and Comfort
5. A sleeping patient has period ic 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
