At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) the inability to fall asleep. Which is the priority nursing action?

Provide a PRN hypnotic medication.

Reassure the client that it is still early.

Evaluate the room environment.

Close the door to the client's room.

Answer and Explanation

The Correct Answer is C

A. Provide a PRN hypnotic medication: Administering a hypnotic should not be the first response without first assessing the underlying cause of the sleep difficulty. Non-pharmacological approaches are safer, especially for older adults who are more sensitive to sedative side effects.
B. Reassure the client that it is still early: Simply reassuring the client does not address the immediate concern of why the client cannot sleep. Dismissing the complaint without assessment may lead to prolonged distress and unresolved sleep disturbances.
C. Evaluate the room environment: Assessing the room for factors like noise, lighting, temperature, and comfort is a priority because environmental factors often contribute significantly to insomnia. Addressing modifiable conditions can promote natural sleep without immediately resorting to medications.
D. Close the door to the client's room: While closing the door might reduce noise, it is a single action that may not fully address all potential environmental issues affecting sleep. A complete evaluation of the environment is necessary first to identify and correct all possible disruptions.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"D"},"D":{"answers":"A"}}

Explanation

SBAR Format:

Situation:
I am holding the digoxin because the client's heart rate is too low.

Background:
The client is a 59-year-old male with hypertension and heart failure. He is currently taking furosemide and digoxin.

Assessment:

Heart rate is 48 beats/minute, blood pressure is 109/76 mm Hg.

Recommendation:
Do you want to recheck the digoxin level to see if there is toxicity? I will monitor the client's heart rate, blood pressure, and perfusion with a continuous monitor until his heart rate returns to normal.

A. Healthcare provider notified, client refuses to have blood glucose taken. B. Blood glucose not obtained because client no longer wants to have finger stick C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified. D. Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed.

Correct Answer is C

Explanation

A. Healthcare provider notified, client refuses to have blood glucose taken: While this option indicates that the healthcare provider was informed and that the client refused, it does not fully capture the client’s expressed reason for refusal. Complete and precise documentation includes the client’s statement in their own words.
B. Blood glucose not obtained because client no longer wants to have finger stick: This phrasing is too casual and lacks the specificity needed for legal and clinical documentation. It does not reflect the client’s exact words or demonstrate that the healthcare provider was informed about the situation.
C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified: This option best meets documentation standards by including the client's direct quote, ensuring accurate and objective recording of the refusal, and noting that the healthcare provider was informed. It provides a clear, detailed account suitable for medical and legal purposes.
D. Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed: Describing the client as uncooperative and irritable is subjective and could be considered judgmental. Proper documentation should remain objective, focusing on the client’s stated concerns rather than labeling their behavior.

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At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) the inability to fall asleep. Which is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The practical nurse (PN) calls the healthcare provider to notify them that the heart rate is too low to administer the digoxin. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have at only one answer selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"D"},"D":{"answers":"A"}}

Explanation

Correct Answer is C

Explanation

During vital sign assessment of a client, the practical nurse (PN) counts the left radial pulse at 88 beats/minute, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 beats/minute with an oxygen saturation of 95%. Which of the following should the PN do first?

An older adult client planning to vacation with a group of senior citizens is concerned about developing constipation. The client shares this concern with the practical nurse (PN) at the retirement home. Which recommendation is best for the PN to provide?

An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?

While performing a physical assessment on a client with chronic obstructive pulmonary disease (COPD), the practical nurse (PN) determines that the client's respiratory rate is 30 breaths/minute. When the PN begins to assess the client's range of motion (ROM), which is the best plan to implement?

A client on a prescribed full liquid diet has a nursing problem of, "Risk for impaired skin integrity related to reduced oral intake." Which snack would be best to provide this client?

A client who is recently diagnosed with stage IV ovarian cancer tells the practical nurse (PN) that the staff on the unit are insensitive and begins to cry. Which intervention(s) should the PN implement? Select all that apply.