To promote adequate sleep for a patient who suffers from a sleep pattern disturbance, what are the most appropriate nursing interventions? (Select all that apply).

Provide personal hygiene before bedtime.

Synchronize the schedule for medications and vital signs.

Administer sleep aids every night at the same time.

Assist the patient to use the toilet before bed.

Straighten and change any soiled bed linens.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: This is a correct choice because providing personal hygiene before bedtime is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to feel more comfortable, relaxed, and refreshed, and to reduce the risk of infection or skin breakdown.

Choice B reason: This is a correct choice because synchronizing the schedule for medications and vital signs is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to have uninterrupted sleep cycles, and to avoid unnecessary disturbances or discomforts from frequent assessments or treatments.

Choice C reason: This is an incorrect choice because administering sleep aids every night at the same time is not an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can cause dependence, tolerance, or adverse effects from the sleep aids, and may not address the underlying cause of the sleep problem. The nurse should use non-pharmacological methods to promote sleep, and administer sleep aids only as prescribed and indicated.

Choice D reason: This is a correct choice because assisting the patient to use the toilet before bed is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to avoid nocturia, which is the need to urinate at night, and to prevent urinary tract infections or incontinence.

Choice E reason: This is a correct choice because straightening and changing any soiled bed linens is an appropriate nursing intervention to promote adequate sleep for a patient who suffers from a sleep pattern disturbance. This intervention can help the patient to maintain a clean, dry, and comfortable sleeping environment, and to prevent skin irritation or infection.

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Correct Answer is C

Explanation

Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.

Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.

Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.

Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.

A. The patient frequently uses an alcohol-based sanitizer for hand hygiene. B. The patient takes acetaminophen 1000 mg every 4 hours around the clock. C. The patient takes alprazolam 0.25 mg every 3 hours. D. The patient rinses with a fluoride mouthwash after brushing the teeth.

Correct Answer is B

Explanation

Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.

Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.

Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 3 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.

Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.

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To promote adequate sleep for a patient who suffers from a sleep pattern disturbance, what are the most appropriate nursing interventions? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Correct Answer is C

Explanation

Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

Correct Answer is B

Explanation

To promote adequate sleep for a patient who suffers from a sleep pattern disturbance, what are the most appropriate nursing interventions? (Select all that apply).

Which is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea?

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

The nurse notes that the patient’s radial pulse is irregular. What is the most appropriate first action of the nurse?

Which type of error is it when the wrong type of medication is administered to the patient?

Which is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery?

Which term will the nurse use to document the patient’s age-related hearing loss?

The nurse applies a warmed blanket to a chilled patient. Which term is used to describe the process by which the blanket increases the patient’s temperature?