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A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?

Administer prescribed diuretics in the evening.

Use overhead lighting when checking equipment.

Keep the door to the client's room closed.

Provide the client with snug-fitting nightwear.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Administering diuretics in the evening may increase the client's need to urinate and disrupt sleep.

B. Using overhead lighting when checking equipment may disrupt the client's sleep and should be avoided.

C. Keeping the door to the client's room closed can reduce noise and disturbances from the hallway, promoting a more restful sleep environment.

D. Providing snug-fitting nightwear may be uncomfortable and restrict movement during sleep.

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Correct Answer is A

Explanation

Rationale:

A. Ensuring that the stool specimen does not contain urine helps to prevent false-positive results, as blood from urine could interfere with the test.

B. Each fecal occult blood test should be performed using a fresh stool specimen to ensure accuracy.

C. Having the client defecate into a bedpan with water is unnecessary and may interfere with the test.

D. Standard precautions, including wearing gloves, are sufficient for handling stool specimens; sterile gloves are not required for this procedure.

A. Tell the nurse that permission from the risk manager is required to view the client's record. B. Contact facility security to remove the nurse from the unit. C. Complete an incident report about the breach of confidentiality. D. Remind the nurse that only staff caring for the client may access the client's record.

Correct Answer is D

Explanation

Rationale:

A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.

B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.

C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.

D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.

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A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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