A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

Encourage the client to ambulate in the hallway 1 hr before bedtime.

Tell the client to avoid drinking fluids 1 hr before bedtime.

Schedule routine care tasks during hours when the client is awake.

Advise the client to leave the television in the room on when trying to fall asleep.

Answer and Explanation

The Correct Answer is C

A. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.

B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.

C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care

activities.

D. Advise the client to leave the television in the room on when trying to fall asleep - Screen

time before bed can interfere with falling asleep due to the stimulating effect of light and content.

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Correct Answer is A

Explanation

A. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.

B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.

C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.

D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.

A. Apply oxygen at 3 L/min per nasal cannula. B. Review the chest x-ray report. C. Flush the catheter with sterile water. D. Obtain a peripheral blood glucose level.

Correct Answer is B

Explanation

A. Apply oxygen at 3 L/min per nasal cannula: While oxygenation is important, there is no

indication in the scenario that the client requires oxygen supplementation at this time. Checking oxygen saturation would be more relevant if there were respiratory concerns.

B. Review the chest x-ray report: This is the most appropriate action before initiating the IV

infusion to ensure proper placement of the central venous catheter and absence of complications such as pneumothorax or malposition.

C. Flush the catheter with sterile water: Flushing the catheter with sterile water is not necessary before starting the infusion, especially without confirming proper catheter placement through chest x-ray.

D. Obtain a peripheral blood glucose level: While monitoring blood glucose levels may be

important in certain clinical situations, it is not directly relevant to initiating an IV infusion of Ringer's lactate via a central venous catheter.

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A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

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Explanation

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Explanation

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