A nurse is assessing a client who has chronic insomnia. Which question would address the highest safety priority for the client?
When did you begin to have trouble sleeping?
Are there any specific factors that you think are affecting your ability to sleep?
Do you have difficulty staying awake when you are driving?
Can you describe your bedtime routine to me?
The Correct Answer is C
Choice A Reason:
Asking “When did you begin to have trouble sleeping?” is important for understanding the onset and duration of the client’s insomnia. However, it does not directly address immediate safety concerns. Chronic insomnia can lead to significant daytime impairment, but the question about the onset of sleep troubles does not identify specific safety risks.
Choice B Reason:
Inquiring about specific factors affecting the client’s ability to sleep can help identify potential causes of insomnia, such as stress, environmental factors, or medical conditions. While this information is valuable for treatment planning, it does not directly address immediate safety concerns.
Choice C Reason:
Asking “Do you have difficulty staying awake when you are driving?” addresses the highest safety priority. Chronic insomnia can lead to excessive daytime sleepiness, which significantly increases the risk of accidents, especially while driving. Identifying whether the client is at risk of falling asleep during potentially dangerous activities is crucial for immediate safety.
Choice D Reason:
Understanding the client’s bedtime routine can provide insights into their sleep hygiene and habits, which are important for managing insomnia. However, this question does not directly address immediate safety concerns related to daytime functioning and the risk of accidents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Retrieving the blood from the laboratory and running each unit at an 8-hour rate is not appropriate. According to transfusion guidelines, blood products should be infused within 4 hours to prevent bacterial growth and reduce the risk of transfusion-related complications1. Infusing blood over 8 hours increases the risk of these complications.
Choice B Reason:
Notifying the laboratory to split the unit into 2 and then infusing each half for 4 hours is also not ideal. While this approach might seem to address the time constraint, it is not a standard practice and could lead to issues with blood product integrity and patient safety2. Blood products are typically not split unless there are specific protocols in place, and this is not a common intervention for managing infusion rates.
Choice C Reason:
Calling the HCP to question the order is the correct intervention. Blood transfusions must be completed within 4 hours to ensure patient safety and maintain the integrity of the blood product3. The nurse should advocate for the patient by questioning any orders that do not align with established guidelines and best practices.
Choice D Reason:
Infusing each unit for 8 hours is incorrect. The maximum duration for infusing a unit of blood is 4 hours4. Extending the infusion time beyond this limit increases the risk of complications such as bacterial contamination and reduced efficacy of the blood product.
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Date of birth is an acceptable client identifier. The Joint Commission specifies that using the date of birth helps ensure accurate identification of the client. This identifier is unique to each individual and is less likely to be duplicated.
Choice B Reason:
Photograph identification is not typically listed as an acceptable identifier by the Joint Commission. While it can be useful in some settings, it is not one of the primary identifiers recommended for ensuring patient safety.
Choice C Reason:
Facility room number is not an acceptable client identifier. The Joint Commission explicitly states that room numbers should not be used as identifiers because they can change and are not unique to the individual.
Choice D Reason:
Client’s full name is an acceptable client identifier. Using the full name helps to accurately identify the client and match them with their medical records and treatment plans.
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