A nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

A. Encourage the client to ambulate in the hallway 1 hr before bedtime: Physical activity too close to bedtime can increase heart rate and body temperature, making it more difficult for the client to fall asleep. While ambulation is beneficial for overall health, it should be scheduled earlier in the day to promote sleep rather than interfere with it.

B. Tell the client to avoid drinking fluids 1 hr before bedtime: Limiting fluids before bed may reduce nighttime awakenings due to urination, but it does not directly address the client’s difficulty falling asleep. This intervention can support sleep quality but is secondary to scheduling care and reducing disturbances.

C. Schedule routine care tasks during hours when the client is awake: Performing nursing care while the client is awake minimizes nighttime interruptions and allows for uninterrupted rest. Prioritizing sleep hygiene by aligning care with the client’s natural sleep-wake cycle is an effective strategy to improve sleep onset and overall sleep quality.

D. Advise the client to leave the television in the room on when trying to fall asleep: Leaving the television on provides light and auditory stimulation, which can interfere with melatonin release and delay sleep onset. This practice is counterproductive and can worsen difficulty falling asleep.

A. "Why do you think your life is not worth it anymore?": Asking “why” can feel judgmental and may cause the client to withdraw rather than share openly. It directs the conversation toward justification rather than safety assessment, delaying the nurse’s responsibility to determine immediate suicide risk.

B. "You can trust me and tell me what you are thinking": While supportive, this statement is too vague and does not address the urgent need to assess suicidal intent. It does not guide the client toward providing specific information needed to evaluate the level of risk and plan for safety.

C. "I need to know what you mean by misery": This response explores the client’s feelings but does not directly address the expressed suicidal thoughts. Focusing on the term “misery” may allow critical details about planning or intent to go unassessed during a potentially dangerous moment.

D. “Do you have a plan to end your life?”: This is an appropriate and essential safety-focused response because it directly assesses the client’s level of suicidal intent and the presence of a plan. Determining whether a plan exists helps the nurse evaluate the immediacy of the risk and initiate protective interventions without delay.