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 A

Explanation

Choice A reason: This is the correct choice because the apical pulse is the most accurate measurement of the heart rate and rhythm. Digoxin is a cardiac medication that affects the heart rate and can cause arrhythmias. Therefore, the nurse should use the apical pulse to monitor the patient's response to the medication.

Choice B reason: This is an incorrect choice because the carotid pulse is not the best site to measure the heart rate before administering digoxin. The carotid pulse is located in the neck and can be affected by external factors such as pressure or movement. The carotid pulse is also not recommended for routine use because it can stimulate the vagus nerve and lower the heart rate.

Choice C reason: This is an incorrect choice because the radial pulse is not the best site to measure the heart rate before administering digoxin. The radial pulse is located in the wrist and can be affected by peripheral factors such as circulation or temperature. The radial pulse can also be inaccurate or irregular if the patient has an arrhythmia.

Choice D reason: This is an incorrect choice because the brachial pulse is not the best site to measure the heart rate before administering digoxin. The brachial pulse is located in the upper arm and can be affected by arm position or blood pressure. The brachial pulse is also not as reliable as the apical pulse for detecting changes in the heart rate and rhythm.

A. Footboard B. Bedframe C. Headboard D. Side rails

Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because tying the restraints to the footboard is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The footboard is the part of the bed that supports the foot end of the mattress. Tying the restraints to the footboard can cause the patient to slide down the bed and increase the risk of strangulation, pressure ulcers, or nerve damage.

Choice B reason: This is the correct choice because tying the restraints to the bedframe is the safest and most appropriate option when the nurse is applying soft wrist restraints to the patient. The bedframe is the metal or wooden structure that supports the mattress and the box spring. Tying the restraints to the bedframe can ensure that the restraints are secure and stable, and that the patient has enough room to move without causing injury or discomfort.

Choice C reason: This is an incorrect choice because tying the restraints to the headboard is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The headboard is the part of the bed that supports the head end of the mattress. Tying the restraints to the headboard can cause the patient to slide up the bed and increase the risk of strangulation, pressure ulcers, or nerve damage.

Choice D reason: This is an incorrect choice because tying the restraints to the side rails is not a safe or appropriate option when the nurse is applying soft wrist restraints to the patient. The side rails are the bars that run along the sides of the bed to prevent the patient from falling out. Tying the restraints to the side rails can cause the patient to twist or bend their wrists and increase the risk of circulation impairment, nerve damage, or skin breakdown.

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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

Which site will the nurse use to measure the patient’s pulse rate before administering the cardiac medication Digoxin?

Correct Answer is A

Explanation

Where will the restraints be tied to the patient’s bed when the nurse is applying soft wrist restraints to the patient?

Correct Answer is B

Explanation

Which assessment finding indicates to the nurse why the patient is having difficulty sleeping at night?

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Which action by the nurse demonstrates the concept of nurse autonomy?

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?

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