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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice Reason:
Occupational Therapist is incorrect. Occupational therapists focus on helping individuals regain or enhance their ability to perform daily activities and tasks. While they might not directly address dysphagia or swallowing concerns, they could assist in modifying the environment or providing adaptive equipment to facilitate eating, such as recommending specialized utensils or adapting seating positions to support safe eating practices.

Choice B Reason:
Physical Therapist is incorrect. Physical therapists primarily concentrate on restoring mobility, strength, and function in individuals who have experienced injuries or illnesses affecting movement. While they might not directly address dysphagia, they could be involved in helping patients with postural adjustments or exercises that indirectly support safe eating and swallowing.

Choice C Reason:
Respiratory Therapist is incorrect. Respiratory therapists specialize in assessing and treating breathing problems and disorders related to the lungs and respiratory system. While they may not focus directly on dysphagia, they can be involved in managing respiratory complications that can arise from aspiration, such as pneumonia. They might assist in suctioning, breathing exercises, or respiratory treatments in cases where aspiration has led to lung issues.

Choice D Reason:
Speech therapists, also known as speech-language pathologists, is correct because it specializes in evaluating and treating communication and swallowing disorders. They work with individuals who have experienced strokes or other conditions affecting swallowing abilities to improve their swallowing function and reduce the risk of aspiration (when food or liquid enters the airway instead of the digestive tract).

A. Open the innermost lower flap of the sterile kit while standing away from the sterile field. B. Open each side flap of the sterile kit individually while pulling to the side. C. Open the outside cover of the sterile kit and remove the dust cover. D. Grasp the outermost flap of the sterile kit while opening away from the body. E. Prepare a dry work surface above the waist level.

Correct Answer is E,C,D,B,A

Explanation

Choice E Reason:

Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.

Choice C Reason:

Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.

Choice D Reason:

Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.

Choice B Reason:

Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.

Choice A Reason:

Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration?

Correct Answer is D

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Placethem in the order of performance. Use all the steps.)

Correct Answer is E,C,D,B,A

Explanation

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