in which of the following ways can a nurse promote sleep for a client who is experiencing insomnia
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NCLEX-RN

NCLEX RN Exam Prep

1. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?

Correct answer: D

Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.

2. After receiving change-of-shift report, which patient should the nurse assess first?

Correct answer: B

Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.

3. A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?

Correct answer: A

Rationale: A history of hepatitis C five years previously would prevent a donor from donating blood for transfusion. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis requiring cholecystectomy one year previously, asymptomatic diverticulosis, and Crohn's disease in remission are not contraindications for blood donation as they do not pose a risk of transmitting infections to the recipient.

4. Which of the following statements best describes footdrop?

Correct answer: B

Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.

5. In which of these patients would rectal temperatures be measured?

Correct answer: B

Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.

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