A nurse in an acute facility is assisting with the development of an in-service about reducing environmental stressors to improve client’s sleep. Which of the following instructions should the nurse include?
Turn on overhead lights briefly when checking IV line
Open curtains between clients semiprivate rooms
Conduct change-of-shift report near the clients’ rooms.
Wear shoes with rubber soles
The Correct Answer is D
A) "Turn on overhead lights briefly when checking IV line.": Turning on overhead lights can disrupt the client’s sleep, especially if done during the night. Light exposure can interfere with the body’s natural circadian rhythm, making it harder for the client to fall asleep and stay asleep. A more appropriate action would be to use a dim light or portable light to minimize disturbance.
B) "Open curtains between clients’ semiprivate rooms.": Opening the curtains between semiprivate rooms could increase noise and visual distractions, which may disturb the client's sleep. Keeping the environment as calm and private as possible is essential to reduce stress and promote restful sleep. Curtains should ideally remain closed to promote privacy and minimize distractions.
C) "Conduct change-of-shift report near the clients’ rooms.": Conducting report near the client's rooms can create unnecessary noise and disturb the client’s sleep. The change-of-shift report should ideally take place in a designated area, away from patient rooms, to reduce noise and disturbances in the environment.
D) "Wear shoes with rubber soles.": Wearing shoes with rubber soles reduces noise when walking, which is particularly important in an acute care setting where patients need rest. Quiet movement helps to maintain a peaceful environment, reducing the environmental stressors that can impact sleep quality for clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Decreased hemoglobin level: A decreased hemoglobin level is not an expected or desirable outcome of taking furosemide. While furosemide can cause fluid loss, it does not directly affect red blood cell production or hemoglobin levels. A decrease in hemoglobin could indicate anemia or another underlying issue, which should be addressed separately.
B) Increased weight of 0.91 kg (2 lb): An increase in weight, especially in a client with heart failure, could indicate fluid retention rather than effective diuresis. Furosemide is a diuretic that helps reduce fluid buildup, so an increase in weight would typically suggest that the medication is not effectively managing fluid overload, which is a key issue in heart failure.
C) Increased urinary output: An increase in urinary output is a clear indicator that furosemide is working effectively. Furosemide is a loop diuretic, which promotes the excretion of sodium and water, leading to increased urine output. This helps reduce fluid volume in the body, which is beneficial for a client with heart failure.
D) Decreased BUN level: While furosemide can affect kidney function, a decrease in blood urea nitrogen (BUN) level is not a direct indicator of the medication’s effectiveness. BUN can be influenced by various factors such as hydration status, kidney function, and protein intake. A decreased BUN level does not directly correlate with furosemide's effectiveness in treating heart failure.
Correct Answer is A
Explanation
A) Inject 15 units of air into the regular insulin vial:
When drawing insulin from both NPH (a long-acting insulin) and regular insulin (a short-acting insulin), the nurse should first inject air into the NPH insulin vial (which is the intermediate-acting insulin) and then inject air into the regular insulin vial. This technique helps to prevent contamination of the regular insulin vial with NPH insulin. After injecting air into the regular insulin vial, the nurse would then withdraw the regular insulin first and then the NPH insulin to avoid contamination of the regular insulin with the NPH insulin.
B) Withdraw 10 units of NPH insulin:
This action is premature, as the nurse has not yet injected air into the regular insulin vial. The correct sequence involves injecting air into both vials before withdrawing any insulin. Therefore, withdrawing NPH insulin at this stage is not the correct next step.
C) Verify the dosage with another nurse:
While verifying the insulin dosage with another nurse is a good practice for ensuring medication safety, this action is not the immediate next step after injecting air into the NPH insulin vial. The priority is to follow the correct sequence of air injection into the vials before withdrawing the insulin. Verification can occur after the insulin is drawn.
D) Place the cap over the needle:
Placing the cap over the needle is a safety step that is generally performed after withdrawing the insulin and preparing the injection. However, this is not the next step in the process of mixing or drawing insulin, so it is not the correct action to take at this point.
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