EAQ EXAM 2

Which statement by the nurse indicates a need for better understanding of the difference between the two stages of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep?

"Dreams occur during NREM sleep but not during REM sleep."

Which action would the nurse take first for a postsurgical client who is still intubated but becoming restless, with an increased pulse rate and blood pressure, when it has been 4 hours since the last dose of pain medication?

Administer the prescribed pain medication.

Which part of the nursing process is documented in discharge and transfer forms?

Assessment

In which time period would the nurse begin preparing for the discharge of a client from the hospital to a nursing home?

At the time of admission

Which action will the nurse include in the plan for care for a client after a bronchoscopy examination?

Check for the gag reflex.

A urine specimen is needed to test for the presence of ketones in a client who is diabetic. Which action would the nurse take when collecting this specimen from an indwelling urinary catheter?

Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine.

Which action would a nurse take to prevent infection from a urinary retention catheter?

Cleansing around the meatus routinely

An older client is admitted to a nursing home after becoming incontinent of urine. The client's rheumatoid arthritis contributes to severely painful joints. Which goal would the nurse address initially in this client?

Control of pain

According to the nursing process, which action would the nurse take after administering pain medication to a postoperative client?

Determine whether the pain medicine relieved the client's pain.

Which instruction would a nurse give to a client to prepare for performance paracentesis?

Empty the bladder before the procedure.

Which action would the nurse take to limit the stress of an older client who is apprehensive about the unfamiliarity and activity in the hospital environment?

Explaining what the client can expect

Which rationale is accurate for why a client who has just undergone a liver biopsy is immediately placed on the right side?

It compresses the blood vessels to prevent bleeding.

Which element of nursing care would be implemented after the client has a lumbar puncture procedure?

Maintaining the client in the supine position for several hours

Which action should the nurse implement to understand the nature of a client's pain? Select all that apply. One, some, or all responses may be correct.

Observe where the client locates the pain. Note whether the pain radiates to any other part of the body.

Which time is the most appropriate for the nurse to collect daily sputum specimens from a client?

On awakening

Which is the nurse's best action when admitting a client for surgery who appears apprehensive and withdrawn?

Orient the client to the unit environment.

Which action would the nurse take first when caring for a postoperative client who reports incisional pain?

Perform a focused assessment of the client.

Which statement made by the nurse demonstrates a need for further understanding about the different stages of non-rapid eye movement (NREM) sleep?

"Stage 2 is the initial stage of deep sleep, whereas stage 4 is the deepest stage of sleep."

Which action would the nurse take first when receiving abnormal diagnostic testing results?

Notify the client's health care provider of the results.

Which statement about rapid eye movement (REM) sleep requires correction?

REM sleep is the deepest stage of sleep.

Which action would the nurse take if a specimen for a routine urinalysis cannot be sent immediately to the laboratory?

Refrigerate the specimen.

In which stage of non-rapid eye movement (NREM) sleep does relaxation progress?

Stage 2

Which stage of non-rapid eye movement (NREM) sleep is characterized by completely relaxed muscles?

Stage 3

Which action would the nurse take when caring for a client with continuous bladder irrigation?

Subtract the amount of irrigant instilled from the output.

Which site would the nurse use to obtain a specimen for urinalysis when a client has an indwelling catheter?

Tubing injection port