A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
Avoid entering the client's room unless requested during the night.
Turn off alarms on bedside monitoring equipment.
Conduct staff communications away from the client's room.
Turn on the client's TV to distract from hallway noise.
The Correct Answer is C
Choice A Reason:
Avoid entering the client's room unless requested during the night is inappropriate. While minimizing entries can reduce disruptions, it's important for the nurse to perform necessary checks and care interventions. Avoiding the room completely might compromise the client's safety or care.
Choice B Reason:
Turn off alarms on bedside monitoring equipment is inappropriate. Disabling alarms can jeopardize patient safety as these alarms often indicate critical changes in the client's condition. Adjusting alarm settings or investigating if noise levels can be reduced without compromising safety would be more appropriate.
Choice C Reason:
Conduct staff communications away from the client's room is appropriate. This intervention helps minimize noise levels near the client's room, creating a quieter environment conducive to sleep. Staff conducting communications away from the room reduces unnecessary disturbances that might affect the client's rest.
Choice D Reason:
Turn on the client's TV to distract from hallway noise is inappropriate. Introducing more noise, such as from a TV, might not effectively address the issue of sleep disturbance due to external noise. Additionally, it's essential to respect the client's preferences, and some may prefer a quiet environment for sleep rather than additional noise from a TV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.
Choice B Reason:
Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.
Choice C Reason:
Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.
Choice D Reason:
Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.
Correct Answer is C
Explanation
Choice A Reason:
"Opioids will be restricted if your partner develops respiratory distress." This statement might cause unnecessary concern or confusion. While opioid use might be adjusted based on the client's condition and symptoms, framing it in terms of restriction might not be the most appropriate way to communicate about pain management in end-of-life care.
Choice B Reason:
"Encourage your partner to eat three large meals each day." Encouraging large meals might not align with the typical dietary approach for someone in end-of-life care, especially if they have reduced appetite or are unable to eat comfortably. End-of-life care often focuses on providing smaller, more manageable meals based on the individual's preferences and capabilities.
Choice C Reason:
"Assume your partner can hear you, even if they do not respond. “This statement encourages the partner to communicate with their loved one, acknowledging the potential for the person to hear even if they are not responsive. Many studies suggest that hearing may persist even in individuals who are unresponsive or in a comatose state, so speaking to them can provide comfort and connection.
Choice D Reason:
"We will use an electric blanket to keep your partner warm." The use of an electric blanket might not be suitable, as the client's sensitivity to temperature might change in end-of-life care. Other methods, such as blankets or adjusting the room temperature, could be more appropriate to ensure comfort without the risks associated with electric blankets.
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