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: A

Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.

Correct Answer: B

Rationale: Jean Watson's Human Caring Theory, developed in the 1970s, defines caring as a healing force transmitted through the nurse's consciousness, connecting to the patient's spirit. She sees nursing as transcending physical acts, fostering openness to a higher human essence. Unlike Benner's skill progression, Leininger's cultural focus, or Swanson's process model, Watson's approach is deeply philosophical, emphasizing transpersonal caring moments like a nurse's empathy soothing a dying patient's fear. Her 10 Carative Factors (e.g., instilling hope) guide this spiritual exchange, influencing holistic nursing practices globally, particularly in palliative care, where emotional and existential support is paramount.

Correct Answer: D

Rationale: When a client with major fecal incontinence reports irritation in the perianal area, the nurse's initial action should be to assess the client's perineum to gather more information. By checking the perineum, the nurse can identify the extent and nature of the irritation, allowing for appropriate interventions to be initiated. This assessment is crucial in developing a comprehensive care plan and addressing the client's immediate needs effectively. Applying the nursing process priority-setting framework helps in planning care and prioritizing nursing actions, making assessment the initial step in this scenario. Applying a fecal collection system (choice A) would be premature without assessing the perineal area first. Similarly, applying a barrier cream (choice B) or cleansing and drying the area (choice C) should follow the assessment to ensure appropriate interventions are chosen based on the assessment findings.

Correct Answer: B

Rationale: The correct answer is B because reducing dairy product intake can help manage symptoms of ulcerative colitis. Dairy products can exacerbate symptoms in some individuals due to their lactose content and may need to be limited or avoided based on individual tolerance levels. Choice A is incorrect because increasing dairy products can worsen symptoms for some ulcerative colitis patients. Choice C is incorrect as while high-fiber foods are generally beneficial, they may exacerbate symptoms during a flare-up. Choice D is also incorrect as while reducing high-fat foods can be beneficial, dairy products are a more specific concern for ulcerative colitis.

Correct Answer: A

Rationale: Sterilization of culture media is critical in microbiology to eliminate contaminants. Autoclaving (choice A) uses moist heat under pressure (typically 121°C at 15 psi for 15-20 minutes) to kill bacteria, spores, and viruses, making it the gold standard for sterilizing liquid media like agar or broth. Boiling (choice B) at 100°C can kill vegetative bacteria but not heat-resistant spores, rendering it inadequate for complete sterilization. Hot air oven (choice C) employs dry heat (160-170°C for 2 hours) and is suitable for glassware, not liquid media, as it may evaporate or degrade nutrients. Ionizing radiation (choice D) is effective for heat-sensitive materials (e.g., plastics), but it's less common for routine media preparation due to cost and equipment needs. Autoclaving is the correct answer (A) because it ensures thorough sterilization of culture media, a process nurses and lab personnel rely on to maintain aseptic conditions for accurate diagnostic cultures.

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: A

Rationale: Frequent position changes prevent contractures in immobile patients by keeping joints mobile and reducing muscle shortening risks. Heat or relaxants offer relief but don't address root immobility, and restraints worsen stiffness. Nurses use this to maintain range of motion, ensuring flexibility and function, a proactive measure against permanent musculoskeletal damage in prolonged stillness.

Correct Answer: A

Rationale: Treating pain first is priority setting (A) need-based order, per definition. Decision-making (B) chooses, literacy (C) understanding, coordination (D) organization not priority-specific. A fits the nurse's focus on Mr. Gary's urgency, making it correct.