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:
"I'll need to sign a separate consent form first." This statement might indicate a misunderstanding of the process or a belief that signing an advance directive requires a separate consent form, which might not be accurate.

Choice B Reason:
“the opportunity to choose what kind of care I receive while I still can. "This statement reflects the understanding that advance directives allow individuals to make decisions about the type of care they wish to receive while they are still capable of expressing their preferences. Advance directives, such as a living will, enable individuals to outline their healthcare preferences in advance, especially in situations where they might not be able to communicate their wishes later due to illness or incapacity.

Choice C Reason:
“living will, there will be a 1-month delay before it is legally binding. “There typically isn't a standard delay before a living will becomes legally binding. Once the living will be properly completed and witnessed according to legal requirements, it becomes effective.

Choice D Reason:
“have my mind about the care I will receive once I sign my living will." The purpose of a living will be to express one's healthcare preferences in advance. While it's possible to update or change a living will if one's preferences change, signing a living will doesn't inherently mean one can easily alter care preferences once it's in place. Amendments or revocations might require specific legal steps.

A. Rub the puncture site with an alcohol pad. B. Apply firm pressure to the puncture site. C. Wrap the client's hand in a warm washcloth. D. Have the client raise his hand.

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.

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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

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