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An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

A.

Drink a mixture of warm water, whiskey, and honey at bedtime.

B.

Establish a regular time for going to bed and getting up.

C.

Ask the healthcare provider for a mild sedative for bedtime.

D.

Take an afternoon nap to make up for missed sleep.

E.

Avoid drinking caffeinated beverages late in the day.

Question Solution

Correct Answer : B,E

Choice A rationale

 

Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.

 

Choice B rationale

 

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.

 

Choice C rationale

 

Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep

.

Choice D rationale

 

Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.

 

Choice E rationale

 

Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.

 


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Correct Answer is D

Explanation

Choice A rationale

Completing an adverse occurrence/incident report is important if an incident occurs, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice B rationale

Ensuring that the restraints are not too tight is important for the client’s safety and comfort, but it does not address the improper securing of the restraints to the bedside rails. The restraints should be secured to a movable part of the bed frame, not the rails.

Choice C rationale

Initiating the facility’s restraint flow sheet is necessary for documentation, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice D rationale

Demonstrating proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.

Correct Answer is A

Explanation

Choice A rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.

Choice D rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.

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