The nurse is caring for a client who has disturbed sleep patterns. Which measures should the nurse implement to promote sleep? Select all that apply.

Correct Answer: A

Rationale: Correct Answer: A (Dimming the lights) Rationale: 1. Dimming the lights helps create a conducive environment for sleep by signaling the body to produce melatonin, a hormone that regulates sleep-wake cycles. 2. Reduced light exposure promotes relaxation and triggers the body's natural sleep mechanisms. 3. Bright lights can interfere with the body's circadian rhythm, making it difficult to fall asleep. Summary of Incorrect Choices: B. Administration of a diuretic is unrelated to promoting sleep and may actually disrupt sleep patterns by causing frequent trips to the bathroom. C. Promoting daytime exercises can be beneficial for overall health but may not directly address disturbed sleep patterns. D. Suggesting a bottle of wine before sleep is not recommended as alcohol can disrupt sleep quality and lead to fragmented sleep patterns.

Correct Answer: B

Rationale: The primary purpose of nursing theories is to provide a framework for nursing practice (Option B). Nursing theories are essential in guiding nurses in their practice by outlining principles, concepts, and values that shape the profession. These theories help nurses understand the rationale behind their actions, make clinical decisions, and provide quality patient care. Option A, which suggests that nursing theories exist to dictate medical interventions, is incorrect. Nursing theories are distinct from medical interventions and focus on nursing-specific concepts such as patient care, holistic health, and human responses to illness. Option C, stating that nursing theories are for establishing healthcare policies, is also incorrect. While nursing theories may influence healthcare policies indirectly by emphasizing the importance of certain approaches to care, their primary goal is to guide nursing practice. Option D, suggesting that nursing theories aim to replace medical guidelines, is incorrect. Nursing theories and medical guidelines serve different purposes, with nursing theories specifically tailored to the unique aspects of nursing practice. In an educational context, understanding the purpose of nursing theories is crucial for nursing students as it forms the foundation of their professional practice. By grasping the role of theories in shaping nursing care, students can better appreciate the significance of evidence-based practice, critical thinking, and effective decision-making in the nursing profession.

Correct Answer: A

Rationale: The correct answer is A) Continue to monitor and record hourly urine output. This is the appropriate action because the urine output is within normal limits for a postoperative male client. It is essential to continue monitoring to ensure there are no sudden changes or trends indicating a potential issue, such as decreased renal function or inadequate fluid intake. Option B) Irrigate the indwelling urinary catheter is incorrect because there is no indication in the scenario that the catheter needs to be irrigated. Doing so without a specific reason can introduce unnecessary risks such as introducing infection. Option C) Increase the I.V. fluid infusion rate is also incorrect as there is no evidence in the scenario to suggest the need for increased fluid intake. Adjusting fluid infusion rates should be based on a comprehensive assessment and not solely on two consecutive hourly urine output measurements. Option D) Notify the physician is unnecessary at this point as the urine output is within normal limits. It is important for nurses to use critical thinking and clinical judgment to determine when physician notification is warranted. In an educational context, this question helps develop the critical thinking skills of nursing students. It emphasizes the importance of monitoring and interpreting patient data accurately before taking action. It also highlights the significance of evidence-based decision-making in nursing practice to provide safe and effective patient care.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Place the client on the left side in the Trendelenburg position. When a client receiving total parenteral nutrition (TPN) demonstrates signs of an air embolism, it is crucial to place the client in the Trendelenburg position on the left side. This position helps to trap the air embolism in the right atrium, preventing it from traveling to the pulmonary artery and causing further complications such as pulmonary embolism. Option A) Place the client in high-Fowlers position is incorrect because it does not help trap the air embolism and prevent its progression. Option B) Notify the physician is important but not the priority when the client's life is at immediate risk. Option C) Stop the total parenteral nutrition is also important but does not address the urgent need to manage the air embolism. Educationally, understanding the correct positioning for managing air embolism in a client receiving TPN is essential for nurses caring for critically ill patients. This question highlights the importance of rapid and appropriate interventions to address life-threatening complications that can arise in clinical settings. It reinforces the significance of prompt action and critical thinking in nursing practice.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Negligence. Negligence refers to the failure to exercise the standard of care that a reasonably prudent person would have exercised in a similar situation, resulting in harm to another person. In the context of nursing practice, failing to take necessary precautions, such as raising side rails for an unconscious patient, constitutes negligence. Option A) Malpractice is a broader term that encompasses professional negligence, so while negligence is a form of malpractice, it is not the specific tort applicable in this case. Option B) Assault involves intentional threat or apprehension of harmful or offensive contact, which is not the case in this scenario. Option C) Battery refers to the intentional harmful or offensive touching of another person without their consent, which is also not applicable in this context. Educationally, understanding the concept of negligence in nursing practice is crucial for ensuring patient safety and quality care. Nurses must adhere to standards of care and take necessary precautions to prevent harm to patients, especially vulnerable populations like unconscious clients. This knowledge helps in promoting a culture of safety and accountability within the healthcare setting.