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A nurse is teaching sleep hygiene to a client who has insomnia.
Which of the following statements should the nurse make? -
ANSWER-"Exercise in the morning after arising."
(Daily exercise has many benefits, including enhancing
cardiovascular, psychological, and musculoskeletal health. The
nurse should recommend that the client avoid exercising within
2 hr of bedtime to limit stimulation and enhance sleep.)
A nurse is preparing to administer enoxaparin subcutaneously
to a client who is postoperative following orthopedic surgery.
The nurse should plan to administer this medication in which of
the following locations? (You will find hot spots to select in the
artwork below. Select only the hot spot that corresponds to
your answer.) - ANSWER-~A is incorrect. The outer posterior
aspect of the upper arms is a site commonly used for
subcutaneous injections. However, it is not recommended for
administration of low molecular weight heparins such as
enoxaparin. The nurse should select another subcutaneous
injection site to promote absorption of the enoxaparin.
,~B is correct. The nurse should administer low molecular
weight heparins, such as enoxaparin, into the anterolateral
aspect of the client's abdomen to promote absorption of the
medication. Other recommended subcutaneous sites for this
medication include the posterolateral aspect of the client's
abdomen, the buttocks, and the upper thighs.
~C is incorrect. The abdomen is a site commonly used for
subcutaneous injections. However, it is not recommended to
administer medications within 5 cm (2 in) of the umbilicus. The
nurse should select another site to administer the enoxaparin.
A nurse is providing teaching about nutrition management to
the parent of an 18-month-old toddler who has phenylketonuria.
Which of the following foods should the nurse recommend? -
ANSWER-Baked potato
(The nurse should recommend low-protein foods to the parent
of a toddler who has phenylketonuria. The nurse should also
recommend the parent offer the toddler fruits, juices, and
cereals with limited phenylalanine.)
A nurse on a medical-surgical unit is caring for a group of
clients. The nurse should identify that which of the following
types of pain are classified as neuropathic? (Select all that
apply.) - ANSWER-~Spinal nerve pain is correct. Neuropathic
pain occurs when there is damage to or impaired function of
nerves due to an injury or illness. Spinal nerve pain is a type of
neuropathic pain.
,~Postherpetic neuralgia pain is correct. Neuropathic pain
occurs when there is damage to or impaired function of nerves
due to an injury or illness.
Postherpetic neuralgia pain is a type of neuropathic pain.
~Phantom limb pain is correct. Neuropathic pain occurs when
there is damage to or impaired function of nerves due to an
injury or illness. Phantom limb pain is a type of neuropathic
pain.
~Fractured hip pain is incorrect. Nociceptive pain occurs when
the client's nerves are intact and functioning properly. Damage
to surrounding tissue, such as with a fractured hip, causes the
client to experience this type of pain. ~Osteoarthritic pain is
incorrect. Nociceptive pain occurs when the client's nerves are
intact and functioning properly. Chronic damage to joints and
surrounding tissue, such as with osteoarthritis, causes the
client to experience this type of pain.
A nurse is assessing for acute pain in a client who is
postoperative. The client has dementia and is nonverbal. Which
of the following findings should the nurse identify as a need for
administration of a PRN pain medication? - ANSWER-
Rapid breathing
(The nurse should identify shallow, rapid breathing as a
nonverbal indicator of acute pain. This change in breathing is a
sympathetic nervous system response to acute pain. The nurse
should further assess the client's respiratory status and
administer a PRN pain medication. Other nonverbal indicators
of pain include muscle tension, restlessness, and moaning.)
, 1,000 mL/8 hr = - ANSWER-125 mL/hr
A nurse is teaching a client about strategies to prevent
recurrent constipation. Which of the following instructions
should the nurse include? (Select all that apply.) - ANSWER-
~"Perform moderate exercises daily" is correct. Physical
activity helps increase peristalsis, which helps prevent
constipation.
~"Add more whole grains to your diet" is correct. Whole grains,
fresh fruits and vegetables, and legumes promote regular
defecation by adding fiber to the diet, which helps prevent
constipation.
~"Increase your fluid intake" is correct. Consuming at least
1,500 mL of water and fruit juice each day helps soften stool
and prevent constipation.
~"Consume a dose of castor oil every day" is incorrect. Castor
oil, a stimulant laxative, can help relieve constipation, but it is
not a safe preventive measure. The nurse should caution the
client that chronic use of laxatives can impair the motility of the
bowels.
~"Take an iron supplement every day" is incorrect. Iron
supplements, antidepressants, and antihistamines are
medications that often cause constipation.
A nurse manager is developing a facility policy about the use of
a fax machine to communicate information from a client's
electronic medical record (EMR). Which of the following should
the nurse include in the policy? - ANSWER-Use a cover sheet
when sending a fax from the health care unit.