The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep
Which action by the nurse is most appropriate for this patient?
a. Provide the patient with a therapeutic back rub.
b. Turn off the alarms on the monitoring devices.
c. Administer an opioid medication to help the patient sleep.
d. Provide the patient with earplugs.
ANS: D
Giving the patient control over stimuli helps to decrease the frustration that results from sensory overload. Adding additional stimuli such as a back rub can increase sensory overload. Turning off monitors and alarms is unsafe; the nurse needs to be aware of critical situations. Opioid medications should not be the first option; however, antianxiety medications and sleep aids may be considered.
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