Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply)

Instruct them to take a long walk an hour before bedtime

Arrange with laboratory to draw blood outside of sleep hours

Encourage patients to fall asleep while watching television

Close the door to patients’ rooms at bedtime

Provide a warm green tea or coffee with evening meal

Answer and Explanation

Correct Answer : B,D

Choice A reason: A long walk an hour before bedtime may stimulate the body, increasing heart rate and alertness, which can delay sleep onset. Physical activity is beneficial earlier in the day to promote sleep, but close to bedtime, it may disrupt the body’s wind-down process, reducing sleep quality in hospitalized patients.

Choice B reason: Arranging blood draws outside sleep hours minimizes nighttime disruptions, which are critical for restorative sleep. Hospital environments often interrupt sleep with procedures, increasing stress and fatigue. This intervention supports the sleep-wake cycle by ensuring uninterrupted rest, promoting better recovery and reducing physiological stress in patients.

Choice C reason: Watching television before sleep exposes patients to blue light, which suppresses melatonin production, a hormone essential for sleep. This can delay sleep onset and reduce sleep quality. Hospitalized patients need a calm, low-stimulation environment to promote rest, making television an inappropriate intervention for sleep promotion.

Choice D reason: Closing the door at bedtime reduces noise and light from hospital corridors, creating a quieter, darker environment conducive to sleep. This minimizes disruptions, supporting the body’s circadian rhythm and melatonin production. A calm environment is essential for hospitalized patients, who often face sleep challenges due to hospital activity.

Choice E reason: Green tea or coffee contains caffeine, a stimulant that inhibits sleep by blocking adenosine receptors, increasing alertness. Consuming these near bedtime can delay sleep onset and reduce sleep quality. Hospitalized patients require interventions that promote relaxation, not stimulation, making this an inappropriate choice for sleep promotion.

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Correct Answer is B

Explanation

Choice A reason: Hypotension occurs in hypovolemic shock when blood volume loss exceeds 15–30%, indicating a later stage. Compensatory mechanisms like vasoconstriction maintain blood pressure initially. Tachycardia precedes hypotension as the body responds to reduced volume, making it a less early sign than increased heart rate.

Choice B reason: Tachycardia is the earliest sign of hypovolemic shock, occurring with 5–15% blood volume loss. The sympathetic nervous system increases heart rate to compensate for reduced cardiac output, maintaining perfusion. This precedes other signs like hypotension or oliguria, making it the first detectable indicator in shock assessment.

Choice C reason: Cool, clammy skin results from vasoconstriction in hypovolemic shock, a compensatory response to maintain blood pressure. This occurs after tachycardia, as the body prioritizes increasing heart rate to compensate for volume loss. Skin changes are a later sign compared to the initial cardiovascular response of tachycardia.

Choice D reason: Decreased urine output (oliguria) occurs in hypovolemic shock when renal perfusion decreases, typically after significant volume loss. This is a later sign, as the kidneys receive reduced blood flow after compensatory mechanisms like tachycardia fail. Tachycardia appears earlier, as it is the body’s initial response to volume loss.

A. Hypomagnesemia B. Hyponatremia C. Hyperchloremia D. Hypokalemia

Correct Answer is A

Explanation

Choice A reason: Hypomagnesemia, low magnesium (normal 1.7–2.2 mg/dL), is indicated by the 0.8 mEq/L value. Magnesium is vital for muscle, nerve, and cardiac function. Low levels can cause tremors, seizures, and arrhythmias. The other values (sodium, chloride, potassium) are within normal ranges, making hypomagnesemia the primary imbalance.

Choice B reason: Hyponatremia, low sodium (normal 135–145 mEq/L), is not indicated, as the sodium level is 140 mEq/L, within normal limits. Hyponatremia can cause neurological symptoms like confusion, but the lab values do not support this diagnosis, and magnesium imbalance is the clear abnormality.

Choice C reason: Hyperchloremia, high chloride (normal 98–106 mEq/L), is not present, as the chloride level is 107 mEq/L, just above normal and not clinically significant. Elevated chloride may occur in dehydration or renal issues, but the primary concern here is the significantly low magnesium level.

Choice D reason: Hypokalemia, low potassium (normal 3.5–5.0 mEq/L), is not indicated, as the potassium level is 3.6 mEq/L, within normal range. Hypokalemia causes muscle weakness and arrhythmias, but the lab values point to hypomagnesemia as the primary electrolyte imbalance in this case.

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Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with suspected hypovolemic shock. Which finding is the earliest indicator of this condition?

Correct Answer is B

Explanation

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

Correct Answer is A

Explanation

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Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply)

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