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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.

Incorrect:

B- Limit documentation to subjective information: This is an incorrect action to take.

Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.

C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.

D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.

A. Check on the client every 10 min during the bath B. Add bath oil to the water after the client gets into the tub C. Drain the tub water before the client gets out D. Allow the client to remain in the bath for 30 min

Correct Answer is C

Explanation

A.If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items such as shower chairs and grab bars.

B.Adding bath oil to the water after the client is in the tub can create a slippery surface, increasing the risk of falls. Bath oil should be added before the client enters the tub or avoided if there is a risk of slipping.

C.Draining the tub water before the client gets out helps prevent slips and falls that can occur if the client attempts to exit the tub while the water is still present. This practice enhances safety by reducing the risk of accidents.

D.Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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