A client presents to the clinic reporting high stress at work, constant headache, and having difficulty falling asleep at night. Over the counter and herbal sleep medications have not worked. The client requests medication to help promote sleep. Which intervention should the nurse implement to initiate a plan of care?

Recommend taking a nap for 15 minutes after lunch.

Encourage the client to eliminate stressful situations.

Determine the client's sleep and activity pattern.

Obtain a PRN prescription to be taken for stress.

Answer and Explanation

The Correct Answer is C

A.   While napping can be beneficial for some people, a nap of 15 minutes may not address the root causes of the client’s sleep difficulties, such as stress and chronic headaches. Additionally, napping during the day can sometimes interfere with nighttime sleep.
B.   Reducing or eliminating stressful situations is a valuable goal for improving overall well-being and sleep quality. However, this recommendation is often not immediately actionable or practical, as stressors in life can be difficult to eliminate completely. It’s more effective to focus on identifying and managing stress through practical and immediate interventions.
C.   Assessing the client's sleep and activity patterns is a critical step in identifying potential causes of sleep disturbances. Understanding the client’s current sleep habits, daily routines, and factors affecting their sleep can help in developing an effective plan of care.
D.   While medication might be necessary for some clients, it should not be the first line of intervention without a thorough assessment. PRN (as needed) medications for stress might not address the root causes of sleep issues and could potentially lead to dependence or other side effects.

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Correct Answer is D

Explanation

A. Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B. "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C. Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D. Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.

A. Document the event in the electronical health record. B. Complete an incident report. C. Inform the nurse on the next shift. D. Notify the healthcare provider.

Correct Answer is B

Explanation

A. Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B. When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C. While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D. Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

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Naxlex Comprehensive Predictor Exams

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Correct Answer is D

Explanation

After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Correct Answer is B

Explanation

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