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concepts of nursing
hesi remediation case study 1
| Question | Answer |
|---|---|
| Which statement is the best description of the sleep pattern for a normal adult? | An adult has four to six sleep cycles, each with non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, during a normal night's sleep. |
| How does the nurse respond to the client’s disclosure that he used his spouse’s diazepam tablets to help him sleep? | “You should not take someone else’s prescription.” |
| Which response by the nurse is most appropriate? | "You should be re-evaluated by a healthcare provider before resuming this medication." |
| The nurse performs a focused assessment on the client, before he sees the healthcare provider (HCP). As part of the assessment, the nurse evaluates the client for which additional symptoms that are commonly associated with sleep deprivation? | Nocturia Sleep apnea |
| Which statements reflect potential expected outcomes for the nursing problem "disturbed sleep pattern related to stress from new job"? | -Client will report a 50% decrease in night awakenings within one week. -Client can identify ways to relieve stress during the day and before bedtime -Client reports fewer incidences of dozing off during the day |
| Which interventions should the nurse add to the client's plan of care? | Monitor bedtime food and beverage intake, which might interfere with sleep. |
| Instruct the client to get out of bed if unable to fall back to sleep within 30 minutes and to do a quiet activity until becoming sleepy. | |
| Which is the best explanation by the nurse for educating the client about OSA? | There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep. |
| The nurse considers which information to be subjective data? | Client states he only sleeps 3 or 4 hours per night the client reports that the CPAP apparatus is uncomfortable the clients wife states he has been yawing a lot at home |
| The charge nurse should assign the client to which room? | A private room near the nursing station and report room. |
| To promote sleep for a hospitalized client, which intervention should the nurse implement? | Close the door to the client's room whenever possible to decrease the noise level and light coming into the room. |
| Which priority action should the nurse implement? | Gently shake the client to awaken him. |
| How should the nurse proceed? | Explain that his O2 sat level is too low and that it wouldn't be safe. |
| Which action should the nurse implement? | Document this expected finding. |
| In managing the client's postoperative care, which task should the nurse delegate to the unlicensed assistive personnel (UAP)? | Obtain pulse oximetry and respiratory rate every 2 hours. serve the prescribed breakfast tray to the client |
| Which observation should be documented in the nurse’s assessment? | Measure the tympanic temperature. observe for excessive drainage |
| Which is the most important action for the nurse to implement? | Wake the client and administer the first dose of the antibiotic. |
| The client has been prescribed levoflloxacin 750 mg PO daily. The nurse has received 250 mg tablets from the pharmacy. How many tablets should the nurse administer? | 3 |
| How should the nurse respond to the client's statement? | "You seem concerned about missing work and the pressures of your job." |
| Which is the most effective method to evaluate improvement of the client's OSA? | Ask Mrs. Olham about her husbands snoring and respiratory pattern at night |
| Which initial response by the nurse is best? | "Please tell me about your son's sleep habits." |
| Which response by the nurse is accurate? | "Many adolescents start developing this type of pattern as they develop independence." |
Created by:
colby.caswell