A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?

Correct Answer: A

Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.

Correct Answer: B

Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.

Correct Answer: C

Rationale: Providing frequent oral care (C) is key with NPPV (e.g., CPAP/BiPAP), as high-flow air dries the mouth, risking sores or discomfort. Q4h SpO2 (A) isn't specific to NPPV. Q15min RR (B) is excessive. 1-2 L/min (D) doesn't apply to NPPV. Oral care enhances comfort, per critical care standards, vital for compliance.

Correct Answer: D

Rationale: Tympanic temp of 37.9°C is normal (36.6-38°C) e.g., high-normal from cough stress. Not high (>38°C), low (<36.6°C), or low-end. Nurses interpret this e.g., monitor trends in acute cases, per standard ranges.

Correct Answer: C

Rationale: Supine position most suppresses respiration post-surgery by limiting diaphragm movement, unlike Fowler's, prone, or side-lying. Nurses adjust this to aid breathing.

Correct Answer: B

Rationale: The correct answer is B. In cirrhosis, decreasing the intake of sodium-rich foods is essential to manage fluid retention and symptoms. Excessive sodium intake can worsen fluid accumulation and lead to complications such as ascites. Therefore, advising the client to decrease sodium-rich foods demonstrates an understanding of the dietary management necessary for cirrhosis. Choices A, C, and D are incorrect because increasing sodium-rich foods can exacerbate fluid retention and complications in cirrhosis, increasing potassium-rich foods is not the primary focus of dietary management in cirrhosis, and decreasing potassium-rich foods is not a key recommendation for managing cirrhosis-related dietary issues.

Correct Answer: A

Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.

Correct Answer: C

Rationale: Subjective data consists of information reported by the patient, reflecting their personal experiences, sensations, or perceptions, which cannot be directly measured by the nurse. The statement 'I feel pain when urinating' is a classic example, as it conveys the patient's subjective sensation of pain, reliant on their verbal report rather than objective observation. This type of data is crucial for understanding symptoms like pain or discomfort that lack visible signs. In contrast, a heart rate of 68 beats per minute is objective, measurable via pulse check. Yellowish sputum and noisy breathing are also objective, observable through sight and sound during assessment. Subjective data, like the patient's pain report, enhances the nurse's ability to assess holistic needs, guiding further inquiry or intervention, such as checking for urinary tract issues, making it distinct from observable, objective findings.

Correct Answer: D

Rationale: Subjective data are clients' perceptions e.g., 'I feel dizzy' reported directly, capturing experiences unmeasurable by others. This contrasts with objective data (e.g., pulse), observable by nurses. Observational recordings are objective, like noting pallor, not perceptions. Ancillary reports (e.g., lab results) are objective, external data, not client-voiced. Subjective data's focus on personal input e.g., pain severity enriches assessment, guiding nurses to explore symptoms' impact (e.g., anxiety's role), making it vital for holistic care and the correct classification here.