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:
Pushing the skin down while gently removing the tape is incorrect. Pushing the skin while removing tape could cause unnecessary discomfort or trauma to the skin and the incision area. Gentle removal of tape without pulling the skin is recommended to avoid skin injury.
Choice B Reason:
Drying the incision with sterile gauze pads is incorrect. Generally, it's advisable not to dry the incision site with sterile gauze pads as this might cause trauma or disruption to the healing tissues. Patting the incision site dry or allowing it to air dry gently after cleansing is preferable.
Choice C Reason:
Lifting the soiled dressing so that the underside faces the client is correct. Lifting the soiled dressing in a manner that the underside faces the client helps prevent potential contamination of the wound by minimizing contact between the external surface of the dressing and the incision site. This technique reduces the risk of introducing pathogens into the wound during the dressing change.
Choice D Reason:
Cleaning around the drain site using horizontal strokes is incorrect. When cleaning around the drain site, it's typically recommended to use gentle and careful motions without specific emphasis on strokes, as this might cause friction or trauma to the area around the drain. Instead, using gentle circular motions or dabbing around the site is often advised for wound care.
Correct Answer is B
Explanation
Choice A Reason:
Keep her arms at the sides of her body with her hands in a relaxed position is wrong. Keeping the hands in a relaxed position at the sides of the body may increase the risk of accidental contact with non-sterile surfaces.
Choice B Reason:
Interlock her fingers and hold her hands away from her body above her waist is wright. Interlocking fingers and holding hands above the waist may increase the risk of accidental contact with non-sterile surfaces.
Choice C Reason:
Clasp her hands together in a relaxed position behind her body at her waist is wrong. This positioning helps maintain sterility by keeping the hands away from potential contaminants and below the waist level. Placing the hands behind the body avoids accidental contact with non-sterile surfaces or objects.
Choice D Reason:
Place one hand over the other against the part of the gown covering her upper body is wrong. Placing hands on the gown covering the upper body may lead to contamination, as the gown is considered non-sterile on the outside. The hands should be kept in a position that minimizes the risk of contact with non-sterile surfaces.
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