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 B

Explanation

Choice A Reason:
Setting the maximum water heater temperature to 54.4° C (130° F) is appropriate. This temperature is too high and could pose a burn risk, especially for someone with impaired vision who might not easily detect very hot water.

Choice B Reason:
Painting the edges of steps for contrast is appropriate. This measure helps increase visibility by creating a visual contrast between the edges of steps and the surrounding area, aiding the individual in identifying the steps more easily, even with reduced vision.

Choice C Reason:
Securing extension cords across walkways is inappropriate. Placing extension cords across walkways can create tripping hazards, particularly for someone with vision loss who may have difficulty seeing these obstacles.

Choice D Reason:
Using 40-watt bulbs to light hallways is inappropriate. While adequate lighting is crucial for individuals with vision impairment, using only 40-watt bulbs might not provide sufficient illumination. It's recommended to use higher-wattage bulbs or brighter lighting sources to ensure better visibility in the home.

A. Add 0.5 mL of diluent to the medication. B. Cleanse the tip of the ampule with an alcohol swab after opening. C. Use a filter needle to aspirate the medication. D. Inject air into the ampule prior to drawing the medication into a syringe.

Correct Answer is C

Explanation

Choice A Reason:

Adding 0.5 mL of diluent to the medication is inappropriate action. Ampules typically contain a single-dose of medication in a liquid form, and dilution is not necessary unless specified by the medication order or manufacturer.

Choice B Reason:

This is not necessary as the tip of the ampule is already sterile before opening. Cleansing after opening does not provide additional benefit and can introduce contaminants.

Choice C Reason:

Using a filter needle to aspirate the medication is inappropriate. Filter needles are not routinely used for administering medication from ample.

Choice D Reason:

This is not appropriate for ampules. Unlike vials, ampules do not require air to be injected. Air injection is necessary only for vials to create pressure, but ampules are opened and medication is drawn directly without the need for air.

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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?

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