A nurse in a provider's office is collecting data from an adult client. The client states that they are having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

"Take a 1-hour nap each day."

"Watch television in bed."

"Drink a glass of milk before bedtime."

"Take a long walk before bedtime."

Answer and Explanation

The Correct Answer is C

A. "Take a 1-hour nap each day.": Napping during the day, especially for an hour, can interfere with the ability to fall asleep and stay asleep at night.

B. "Watch television in bed.": The bed should be used only for sleep and intimacy. Watching TV provides "blue light" and mental stimulation that disrupts the circadian rhythm.

C. "Drink a glass of milk before bedtime.": Milk contains L-tryptophan, an amino acid that serves as a precursor to serotonin and melatonin, which helps induce sleep.

D. "Take a long walk before bedtime.": Vigorous exercise shortly before bed increases core body temperature and heart rate, which can make falling asleep more difficult.

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Correct Answer is D

Explanation

A. Headache: This can be a sign of a reaction, but it is not as life-threatening as respiratory distress.

B. Urticaria: (Hives) This indicates a mild allergic reaction. While important, it is not the top priority.

C. Hyperthermia: A fever can indicate a febrile non-hemolytic reaction or a hemolytic reaction. It is serious but secondary to airway/breathing.

D. Dyspnea: Using the ABC (Airway-Breathing-Circulation) priority framework, difficulty breathing (dyspnea) is the most critical finding. It could indicate a severe hemolytic reaction or circulatory overload (TACO) and requires immediate intervention.

A. Notify the charge nurse of the client's condition. B. Review the client's most recent SaO2 level in the medical record. C. Check the client's medical records to see which medications were recently administered. D. Recheck the client's SaO2 level after having the client cough and clear their throat.

Correct Answer is D

Explanation

A. Notify the charge nurse of the client's condition.: While necessary, it is not the first action in an acute assessment situation.

B. Review the client's most recent SaO2 level in the medical record.: This provides context but does not address the client's current acute respiratory distress.

C. Check the client's medical records to see which medications were recently administered.: This delays immediate intervention for a potentially unstable client.

D. Recheck the client's SaO2 level after having the client cough and clear their throat.: This is a simple, immediate nursing intervention to clear the airway and ensure the reading is accurate and not affected by secretions.

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A nurse in a provider's office is collecting data from an adult client. The client states that they are having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?

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