The nurse is caring for a hospitalized patient who needs vital signs and assessments every 4 hours
The nurse last assessed the patient at midnight, and at 2 AM the nurse answers the call light and helps the patient to the bathroom. To promote good sleep, what action by the nurse is best?
a. Ask the patient if a sleeping medication is needed.
b. Assess the patient now and again at 6 AM.
c. Tell the patient you will be back in 2 hours.
d. Assess the patient at 4 AM while being very quiet.
B
The nurse can use judgment to assess the patient more often than ordered. In this case, assessing the patient 2 hours early and rescheduling the next assessment conforms to the prescribed maxi-mum time between assessments and allows the patient 4 hours of uninterrupted rest. The patient may or may not want a sleeping pill, but sleep without medication is best.
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