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Questions 163

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Question 1 of 5

The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?

Correct Answer: C

Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.

Question 2 of 5

The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:

Correct Answer: C

Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.

Question 3 of 5

An elderly man has just returned from the operating room where he spent several hours in lithotomy position during a perineal prostatectomy. Which assessment should the nurse make because the client was in lithotomy position during surgery?

Correct Answer: A

Rationale: Prolonged lithotomy position risks nerve compression and impaired circulation in the lower extremities, necessitating assessment of pulses, paresthesias, and pain to detect complications like compartment syndrome.

Question 4 of 5

The nurse is preparing to give a heparin injection to a client who is severely malnourished and has minimal adipose tissue. Which method of injection would be appropriate for this client?

Correct Answer: C

Rationale: For a malnourished client with minimal adipose tissue, heparin should be injected at a 90-degree angle using a 25-gauge needle to ensure subcutaneous delivery without hitting muscle.

Question 5 of 5

The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed

Correct Answer: C

Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B,
D) follow correct infection control protocols.

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