The nurse is caring for a patient with the following vital signs:
Temperature: 98.9°F
Pulse: 94
Respirations: 20
Blood pressure: 144/94
Pulse oximetry: 94%
What is the priority action of the nurse?

Choice A reason: This is an incorrect choice because sleep-wake pattern is not the most important assessment to determine if a patient is receiving sufficient sleep. Sleep-wake pattern is the cycle of sleeping and waking that follows a circadian rhythm. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep-wake patterns that suit their needs and preferences.

Choice B reason: This is an incorrect choice because hours of sleep each night is not the most important assessment to determine if a patient is receiving sufficient sleep. Hours of sleep each night is the duration of sleep that a person gets in a 24-hour period. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep needs and requirements that vary according to age, lifestyle, health, and other factors.

Choice C reason: This is the correct choice because whether the patient feels rested is the most important assessment to determine if a patient is receiving sufficient sleep. Feeling rested is the subjective perception of the patient about their sleep quality and quantity. It is a reliable indicator of sleep sufficiency, as it reflects the patient's satisfaction and well-being after sleeping.

Choice D reason: This is an incorrect choice because frequency of nocturia is not the most important assessment to determine if a patient is receiving sufficient sleep. Frequency of nocturia is the number of times that a person has to urinate at night. However, it is not a reliable indicator of sleep quality or quantity, as it may be influenced by other factors such as fluid intake, medication, or medical conditions.

Choice A reason: This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.

Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.

Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.