A nurse is caring for a client who is postoperative and reports having difficulty sleeping. Which of the following interventions should the nurse recommend?

Offer the client hot chocolate or tea prior to rest periods.

Encourage the client to ambulate in the hallway before resting.

Cluster routine care activities to allow rest periods without interruptions.

Encourage the client to watch television to relax.

Answer and Explanation

The Correct Answer is C

A. Offer the client hot chocolate or tea prior to rest periods. While warm beverages can be comforting and help some people relax, hot chocolate and many teas contain caffeine, which can interfere with sleep. Even decaffeinated options might not be the best choice close to bedtime due to the fluid content, which could increase the need for nighttime urination, disrupting sleep.
B. Encourage the client to ambulate in the hallway before resting. Light physical activity, such as ambulating, can help promote relaxation and reduce muscle tension, which might aid sleep. However, it is essential to consider the client's postoperative status and ensure that ambulation is safe and appropriate for their condition. Overexertion close to bedtime might have the opposite effect and increase alertness.
C. Cluster routine care activities to allow rest periods without interruptions. This is a highly recommended intervention. By clustering care activities, the nurse can minimize disturbances during rest periods, allowing the client to have longer, uninterrupted sleep. This is crucial in a hospital setting where frequent interruptions can significantly impact the quality of sleep.
D. Encourage the client to watch television to relax. While watching television can be relaxing for some, it can also be stimulating and potentially interfere with sleep due to the light and noise. Blue light emitted from screens can suppress melatonin production, making it harder to fall asleep. Therefore, this is generally not recommended as a sleep aid.

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Correct Answer is D

Explanation

A. Tingling in the toes: Tingling in the toes is not specific to CRPS. It might be a general symptom but is not a classic sign of CRPS.
B. 1+ dorsalis pedis pulse: A weak pulse might indicate reduced circulation but is not specific to CRPS. CRPS is more associated with pain, swelling, and changes in skin color or temperature.
C. Capillary refill of 3 seconds: A capillary refill time of 3 seconds is prolonged and suggests possible circulation issues, but it is not a specific manifestation of CRPS.
D. Increased edema of the foot: Increased edema of the foot is a common manifestation of CRPS. CRPS often presents with localized swelling, along with other symptoms like pain and changes in skin color or temperature.

A. Flush the port with heparin prior to administering the medication. B. Inject the medication into the port closest to the client. C. Pinch the tubing below the injection port prior to administration. D. Administer the medication over 10 seconds.

Correct Answer is B

Explanation

A. Flush the port with heparin prior to administering the medication. Heparin is not typically used to flush the port before administering IV medications; saline is generally used for flushing.
B. Inject the medication into the port closest to the client. This ensures the medication is delivered quickly and effectively, minimizing dilution and maximizing its effect.
C. Pinch the tubing below the injection port prior to administration. Pinching the tubing can help ensure the medication goes into the client quickly but should be done only if specified by protocol.
D. Administer the medication over 10 seconds. Fentanyl should be administered slowly over 1-2 minutes to prevent rapid administration-related side effects like hypotension or respiratory depression.

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A nurse is caring for a client who is postoperative and reports having difficulty sleeping. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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