A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?
Conduct change-of-shift report near the clients' rooms.
Turn on overhead lights briefly when checking IV lines.
Open curtains between clients in semiprivate rooms.
Wear shoes with rubber soles.
The Correct Answer is D
Wearing shoes with rubber soles can minimize noise and provide a quieter environment for the clients. It helps reduce disruptions caused by footsteps, especially during nighttime when clients are trying to sleep.
Conducting change-of-shift report near the clients' rooms can lead to increased noise levels and disturb clients' sleep. It is best to conduct report in a designated area away from patient rooms to minimize disruptions.
Overhead lights should be avoided during nighttime or sleep hours as they are bright and can disrupt a client's sleep. Instead, nurses should use a low-intensity light or a flashlight to check IV lines or attend to other needs. This helps minimize disruptions to the client's rest.
Opening curtains between clients in semiprivate rooms can compromise privacy and contribute to increased noise levels. It is important to provide privacy for clients, especially during their rest periods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Dark red urine following a transurethral resection of the prostate (TURP) can indicate active bleeding or hematoma formation. It is important to notify the provider because further assessment and intervention may be necessary to address the source of the bleeding and prevent complications.
Frequent urge to urinate is expected after a TURP procedure as the bladder recovers and adapts to the changes. This is not a concerning finding and does not require immediate reporting to the provider.
Urine output of 300 mL over 8 hours can be considered adequate, especially in the early postoperative period. The nurse should continue to monitor the client's urinary output, but this finding does not require immediate reporting.
Occasional small clots in the urine can be expected after a TURP procedure due to the healing process and sloughing of tissue. However, if the clots become large or obstructive, or if there is a sudden increase in the frequency of clots, it should be reported to the provider.
Correct Answer is B
Explanation
The nurse should describe hyperactive bowel sounds as sounds that are loud, high-pitched, and increased in frequency and intensity. They are more frequent than the normal bowel sounds, with a rapid succession of sounds occurring at a rate greater than 5 to 30 sounds per minute.
Hyperactive bowel sounds can be heard in conditions such as gastroenteritis, diarrhea, and early mechanical bowel obstruction. They indicate increased bowel motility and are often associated with increased peristalsis.
To differentiate hyperactive bowel sounds from normal or hypoactive bowel sounds, the nurse can explain that hypoactive bowel sounds are decreased or absent sounds that occur when the bowel motility is decreased, such as in conditions like paralytic ileus or after abdominal surgery. Normal bowel sounds are typically soft, low-pitched, and occur at a rate of 5 to 30 sounds per minute.
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