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A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action?
- A. Maintain the restraints to protect patient safety.
- B. Remove the restraints periodically to check skin integrity.
- C. Remove the restraints periodically for range of motion.
- D. Assess and intervene for causes of agitation. Answer Key
Correct Answer: D
Rationale: The correct answer is D: Assess and intervene for causes of agitation. In a critically ill patient, agitation while intubated could indicate underlying issues like pain, delirium, or inadequate sedation. By assessing and addressing the root cause of agitation, the nurse can improve patient comfort and prevent potential harm from restraints. Removing restraints periodically for skin integrity (B) and range of motion (C) is important but should not be the primary focus when agitation is present. Maintaining restraints (A) without addressing the agitation could lead to increased distress and potential complications.
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Which interventions can the nurse use to facilitate communication with patients and families who are in the process of making decisions regarding end- of-life care options? (Select all that apply.)
- A. Communication of uniform messages from all healthca re team members
- B. An integrated plan of care that is developed collaborat ively by the patient, family, and healthcare team
- C. Facilitation of continuity of care through accurate shift -to-shift and transfer reports
- D. Limitation of time for families to express feelings in order to control family grief
Correct Answer: A
Rationale: The correct answer is A: Communication of uniform messages from all healthcare team members. This intervention is crucial to ensure consistency in information provided to patients and families, reducing confusion and enhancing trust. When all team members convey the same messages, it helps in clarifying options and facilitating decision-making.
Choices B and C are incorrect as they focus on care planning and continuity, which are important but not specifically related to facilitating communication in end-of-life care decisions. Choice D is incorrect as it suggests limiting time for families to express feelings, which can hinder effective communication and support during such a sensitive time.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
- A. Case management.
- B. Team nursing.
- C. Primary nursing.
- D. Functional nursing.
Correct Answer: C
Rationale: The correct answer is C: Primary nursing. Primary nursing is a care delivery model where one nurse is responsible for the total care of a group of clients over a 24-hour period. This promotes continuity of care, individualized attention, and better nurse-client relationships. In primary nursing, the nurse plans and directs care, coordinates with other healthcare team members, and serves as the main point of contact for the clients.
A: Case management involves coordinating care across different healthcare providers and services, not necessarily focusing on a specific group of clients over a 24-hour period.
B: Team nursing involves a team of healthcare providers working together to deliver care, rather than one nurse being responsible for a specific group of clients over a 24-hour period.
D: Functional nursing divides tasks among different healthcare team members based on their specific skills, which may not provide the same level of continuity and individualized care as primary nursing.
The nurse wishes to assess the quality of a patient’s pain. Which questions is appropriate to obtain this assessment if the patient is able to give a verbal response?
- A. “Is the pain constant or intermittent?”
- B. “Is the pain sharp, dull, or crushing?”
- C. “What makes the pain better? Worse?”
- D. “When did the pain start?”
Correct Answer: B
Rationale: The correct answer is B because asking if the pain is sharp, dull, or crushing helps assess the quality of pain, providing specific information on the type of sensation felt. This is crucial for understanding the underlying cause and guiding appropriate treatment.
A: Asking about pain being constant or intermittent addresses duration, not quality.
C: Inquiring about what makes pain better or worse focuses on triggers, not quality.
D: Asking when the pain started addresses onset time, not quality.
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
- A. Activate the rapid response team.
- B. Provide reassurance to the patient.
- C. Call the health care provider to reinsert the tube.
- D. Manually ventilate the patient with 100% oxygen.
Correct Answer: D
Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.
When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.