The nurse is educating a group of nursing students about end-of-life care. Which statement by a student indicates the need for further teaching?
- A. Terminally ill patients may benefit from around-the-clock analgesics.
- B. Hospice care can be initiated when curative treatment is no longer effective.
- C. Hydration and nutrition should always be maintained until the patient dies.
- D. Emotional support is a key component of end-of-life care.
Correct Answer: C
Rationale: The correct answer is C because maintaining hydration and nutrition until the patient dies is not always appropriate in end-of-life care, as some patients may be unable to tolerate oral intake or may be close to the end of life where artificial nutrition and hydration may not provide benefit and may even cause discomfort.
Explanation:
A: A is correct because terminally ill patients may indeed benefit from continuous pain management to ensure comfort.
B: B is correct because hospice care is typically initiated when curative treatment is no longer effective and focuses on providing comfort and quality of life.
D: D is correct because emotional support is crucial in end-of-life care to address the patient's psychological well-being and provide comfort.
In summary, choice C is incorrect as it does not consider individual patient needs and preferences in end-of-life care.
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An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable, and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to:
- A. Give PRN lorazepam (Ativan) and cancel the transfer.
- B. Inform the receiving nurse and then transfer the patient.
- C. Notify the health care provider and postpone the transfer.
- D. Obtain an order for restraints as needed and transfer the patient.
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider and postpone the transfer. The new onset confusion in an elderly patient in the ICU can be a sign of delirium, which is a serious condition that requires prompt evaluation and management. By notifying the healthcare provider, they can assess the patient's condition, order appropriate tests, and adjust the treatment plan as needed. Postponing the transfer allows for further observation and intervention to address the underlying cause of the confusion.
Choice A (Give PRN lorazepam and cancel the transfer) is incorrect because administering lorazepam may worsen the confusion in an elderly patient and should not be done without proper evaluation.
Choice B (Inform the receiving nurse and then transfer the patient) is incorrect because transferring the patient without addressing the new onset confusion can lead to potential complications and delay in appropriate management.
Choice D (Obtain an order for restraints as needed and transfer the patient) is incorrect because using restraints should only be considered as a
The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)
- A. Airway clearance therapies
- B. Antibiotic therapy
- C. Nutritional support
- D. Tracheostomy
Correct Answer: A
Rationale: The correct answer is A: Airway clearance therapies. In cystic fibrosis (CF), mucus buildup in the lungs can lead to infections and breathing difficulties. Airway clearance therapies help loosen and clear this mucus, improving lung function. Antibiotic therapy (B) is used to treat infections but is not specific to CF treatment. Nutritional support (C) is crucial in CF due to malabsorption, but it is not the primary treatment. Tracheostomy (D) is a surgical procedure to create an airway bypassing the upper respiratory tract and is not a standard treatment for CF.
A family of a young girl who has been diagnosed with leukemia has travelled 12 hours by car to admit her to the ICU and be with her during her treatment. Which aspect of the critical care family assistance program would most likely be needed by this family initially?
- A. Educational materials
- B. Weekly group family information sessions
- C. Hospitality programs
- D. Pet therapy
Correct Answer: C
Rationale: The correct answer is C: Hospitality programs. Given the family's long journey and the stressful situation of having a child diagnosed with leukemia, their immediate need would likely be for accommodations and support services provided by hospitality programs, such as lodging, meals, transportation assistance, and emotional support. This would help alleviate the burden of their travel and allow them to focus on being with their daughter in the ICU.
Incorrect answers:
A: Educational materials - While education is crucial for families, it may not be the most immediate need in this situation.
B: Weekly group family information sessions - These sessions may be helpful for support and information-sharing, but they are not as urgent as addressing the family's immediate needs.
D: Pet therapy - While pet therapy can provide emotional support, it may not be the most pressing need for this family at the moment.
The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient’s noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse?
- A. Activate the rapid response system.
- B. Place the patient in Trendelenburg position.
- C. Assess the cuff for proper arm size.
- D. Administer 0.9% normal saline bolus.
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Assess the cuff for proper arm size):
1. The cuff blood pressure (70/40 mm Hg) is significantly lower than the arterial blood pressure (108/70 mm Hg).
2. Discrepancy suggests cuff size mismatch, leading to inaccurate readings.
3. Assessing cuff size ensures accurate blood pressure measurement.
4. Ensures appropriate interventions based on accurate readings.
Summary of Incorrect Choices:
A: Rapid response not warranted based solely on blood pressure discrepancy.
B: Trendelenburg position not indicated for cuff size issue.
D: Normal saline bolus not appropriate without accurate blood pressure measurement.
The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?
- A. Knowledge deficit regarding impending surgery.
- B. Ineffective management of treatment regimen.
- C. Activity intolerance related to postoperative pain.
- D. Noncompliance with prescribed exercise plan.
Correct Answer: C
Rationale: Step-by-step rationale for choice C:
1. Activity intolerance is a priority nursing problem postoperatively due to pain.
2. Postoperative pain can limit the client's ability to perform activities.
3. Addressing activity intolerance is crucial for promoting recovery and preventing complications.
4. Delaying the teaching session helps the nurse focus on managing pain first.
Summary of why other choices are incorrect:
- Choice A: Knowledge deficit can be addressed after managing immediate postoperative issues.
- Choice B: Treatment regimen management is important but may not be as urgent as addressing activity intolerance related to pain.
- Choice D: Noncompliance with exercise plan can be addressed once the client's pain and activity intolerance are under control.