Author Question: The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight ... (Read 29 times)

piesebel · **on:** Jul 23, 2018

The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake?

a. The patient was waiting to talk with the nurse.
b. The patient misses his family and is lonely.
c. The patient's sleep-wake cycle preference is late evening.
d. The patient has been kept up with the noise on the unit.

Question 2

When discontinuing a peripheral IV access, the nurse should (Select all that apply.)

a. Use scissors to remove the IV site dressing and tape.
b. Keep the catheter parallel to the skin while removing it.
c. Apply firm pressure with sterile gauze during removal.
d. Stop the infusion before removing the IV catheter.
e. Wear sterile gloves and a mask.
f. Apply pressure to the site for 2 to 3 minutes after removal.

vboyd24 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: C
All persons have biological clocks that synchronize their sleep-wake cycle. This explains why some individuals fall asleep in the early evening and some late evening or early morning. This patient is awake and alert enough to do a puzzle. The individual's sleep-wake preference is probably late evening. Waiting to talk with the nurse, being lonely, and noise on the unit may contribute to lack of sleep, but the best explanation for the patient being awake is the biological clock.

Answer to Question 2

ANS: B, D, F
The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicat-ed to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.