a nurse is working with mr l a client who is being seen for disrupted sleep patterns the nurse encourages mr l to verbalize his feelings about sleep a

NCLEX-RN

NCLEX RN Exam Prep

1. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?

A. The client most likely has a mental illness that should be treated before addressing sleep issues
B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
C. The client may become tired once they start talking
D. None of the above

Correct answer: B

Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.

2. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

A. Administer the feeding as ordered
B. Pull the feeding tube out approximately 3 cm
C. Flush the feeding tube with 60 cc of water
D. Contact the physician

Correct answer: A

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

3. When are manual hematocrits done?

A. to monitor anemia
B. by using a microhematocrit tube.
C. to measure the percentage of plasma to cells.
D. All of the above.

Correct answer: D

Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.

4. The abbreviation ac is defined as _____________.

A. before the meal
B. with the meal
C. after the meal
D. ante cibum

Correct answer: A

Rationale: The correct answer is 'before the meal.' The abbreviation 'ac' is derived from the Latin term 'ante cibum,' which translates to 'before a meal.' Choices B, C, and D are incorrect because 'ac' does not refer to 'with the meal,' 'after the meal,' or 'ante corpis.' It specifically denotes something occurring before a meal, making option A the correct choice in this context.

5. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?

A. Blood pressure guidelines for children are based on age.
B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
C. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.

Correct answer: D

Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.