A nurse is planning care for a client who reports having difficulty sleeping. Which of the following interventions should the nurse include in the plan of care?

Provide a cup of hot chocolate prior to bedtime.

Schedule exercise activities at least 3 hr before bedtime.

Keep soft music playing at bedtime and throughout the night.

Schedule mealtime 2 hr before bedtime.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Providing a cup of hot chocolate prior to bedtime is not a suitable intervention for a client reporting difficulty sleeping. Hot chocolate contains caffeine, which can act as a stimulant and interfere with sleep. Caffeine is known to disrupt sleep patterns and should be avoided close to bedtime.

Choice B rationale:

Scheduling exercise activities at least 3 hours before bedtime is the correct intervention for a client experiencing difficulty sleeping. Regular exercise promotes better sleep quality by helping to regulate the sleep-wake cycle and improve sleep duration. However, exercising too close to bedtime can have a stimulating effect, making it harder for the client to fall asleep. By scheduling exercise activities earlier in the day, the client's body will have sufficient time to wind down before bedtime, leading to improved sleep.

Choice C rationale:

Keeping soft music playing at bedtime and throughout the night might not be effective for everyone. While soft music can create a calming environment and help some individuals relax, it may not address the underlying causes of the client's difficulty sleeping. Additionally, some people might find background noise disruptive to their sleep. Therefore, this option might not be as effective as adjusting the timing of exercise.

Choice D rationale:

Scheduling mealtime 2 hours before bedtime is generally a good practice, but it might not directly address the client's reported difficulty sleeping. Consuming heavy or spicy meals close to bedtime can cause discomfort and indigestion, which might interfere with sleep. However, adjusting mealtime alone might not be sufficient to resolve the client's sleep issues, especially if other factors are contributing to their insomnia.

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Correct Answer is A

Explanation

Choice A rationale:

Instructing the client to remain supine for 10 minutes after inserting a vaginal suppository helps ensure proper absorption of the medication. This position allows the suppository to stay in contact with the vaginal mucosa, promoting optimal drug absorption. This is an essential nursing action to maximize the therapeutic effect of the medication.

Choice B rationale:

Applying sterile gloves after cleansing the perineal area is not necessary when administering a vaginal suppository. While maintaining cleanliness is important, the use of sterile gloves is not typically required for this procedure. Clean, non-sterile gloves are sufficient to maintain aseptic technique during the administration.

Choice C rationale:

Inserting the suppository 3 to 4 cm (1 to 1.5 in) into the vagina is an appropriate depth for vaginal suppository insertion. The nurse should follow this guideline to ensure that the medication reaches the appropriate location within the vaginal canal, optimizing absorption and effectiveness.

Choice D rationale:

Placing the client in the lateral semi-prone recumbent position is not a standard position for administering a vaginal suppository. The suppository is typically administered with the client lying on their back (supine) to facilitate insertion and medication absorption. Placing the client in the position described would not provide the optimal angle for insertion.

A. Slowly instill 400 to 500 mL of the prescribed solution. B. Clamp the drainage tubing distal to the injection port. C. Use a syringe with a 19-gauge needle. D. Withdraw the irrigation solution into the syringe.

Correct Answer is A

Explanation

Choice A rationale:

During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.

Choice B rationale:

Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.

Choice C rationale:

Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.

Choice D rationale:

Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.

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A nurse is planning care for a client who reports having difficulty sleeping. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to administer a vaginal suppository to a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

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