A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?
Cluster nursing activities so that the patient has uninterrupted rest periods.
Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
Administer sedatives or opioids at bedtime to promote sleep.
Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep
The Correct Answer is A
A. Clustering nursing activities helps to minimize interruptions, allowing the patient to have longer periods of uninterrupted rest, which is essential for recovery and reducing sensory disturbances from sleep deprivation.
B. Silencing alarms could compromise patient safety and is not recommended.
C. Administering sedatives or opioids should be done cautiously and is not a first-line approach for promoting sleep, especially if non-pharmacological methods can be effective.
D. While reducing nighttime assessments may help with sleep, it is not always feasible and should be balanced with the need for monitoring the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The radial pulse is not as reliable as the carotid pulse in assessing circulation during CPR.
B. The carotid pulse is the most reliable site to assess circulation in an adult during CPR because it is closest to the heart and will reflect the true status of central circulation.
C. The apical pulse is not typically assessed during CPR due to its location and difficulty in palpation.
D. The popliteal pulse is not a recommended site for assessing circulation during CPR.
Correct Answer is B
Explanation
A. Obtaining a stat chest x-ray is important if catheter misplacement is suspected, but in this situation, ensuring the accuracy of the pressure reading through proper leveling and zeroing is the priority.
B. Zero referencing and leveling the catheter at the phlebostatic axis is essential to ensure accurate readings of the pulmonary artery pressure, which is critical for patient assessment and management.
C. Increasing supplemental oxygen is unnecessary given the patient’s stable oxygen saturation and normal respiratory status.
D. While notifying the provider is important, ensuring the accuracy of the pressure reading by leveling and zeroing the catheter should be done first.
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