Nokea
A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
- A. Administer fentanyl (Duragesic) 25 mg IV bolus.
- B. Administer midazolam 2 mg IV now.
- C. Increase the rate of the morphine infusion by 50%.
- D. Request an order for a paralytic agent.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Midazolam is a benzodiazepine used for sedation and anxiolysis.
2. It acts quickly and has a short duration of action, suitable for acute agitation.
3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility.
4. Lorazepam is specifically ordered for this patient, indicating its appropriateness.
5. Administering midazolam addresses the patient's agitation efficiently and safely.
Summary of why other choices are incorrect:
A: Fentanyl is an opioid analgesic, not ideal for managing agitation.
C: Increasing morphine infusion can exacerbate sedation or respiratory depression.
D: Paralytic agents are used for neuromuscular blockade, not agitation control.
You may also like to solve these questions
The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care?
- A. Ask one family member to assist with the patients bath.
- B. Encourage family members to stay longer at each visit.
- C. Focus nursing efforts on the patients legal next of kin.
- D. Ask the family to complete the Critical Care Family Needs Inventory.
Correct Answer: D
Rationale: The correct answer is D: Ask the family to complete the Critical Care Family Needs Inventory. This tool helps assess the family's needs and concerns, enabling the nurse to tailor care accordingly. By understanding the family's specific needs, the nurse can provide appropriate support and information, fostering better involvement and understanding.
A: Asking one family member to assist with the patient's bath may not address the overall family's needs or involvement in care.
B: Encouraging family members to stay longer does not necessarily address their specific needs or facilitate effective communication.
C: Focusing solely on the legal next of kin may exclude important family members who also need support and involvement in the patient's care.
A physician visits a patient in the ICU while the nurse is out. The patient complains that the pain medication is not effective and that he would like to receive an increased dose. The physician has the nurse paged and consults with him in the hallway regarding the patients request for stronger pain medication. The nurse explains that patient was started on a morphine drip only 20 minutes ago and that the drug has not had time to take effectyet. The physician agrees and tells the patient to give it just a bit more time. Which component of a healthy work environment is most evident in this scenario?
- A. Skilled communication
- B. Appropriate staffing
- C. True collaboration
- D. Recognizing signs of imminent stroke and paging the physician
Correct Answer: C
Rationale: The correct answer is C: True collaboration. In this scenario, the physician consults with the nurse to understand the situation and collaborates on the best course of action for the patient's care. This demonstrates effective teamwork, communication, and mutual respect between healthcare professionals, which are key components of a healthy work environment.
Choice A (Skilled communication) is not the best answer because while communication between the physician and nurse is important, the focus in this scenario is more on collaboration and teamwork.
Choice B (Appropriate staffing) is not the best answer as the scenario does not specifically address staffing levels but rather the interaction and collaboration between the physician and nurse.
Choice D (Recognizing signs of imminent stroke and paging the physician) is incorrect as it is unrelated to the scenario described, which is about the physician and nurse collaborating on patient care.
A patient in a critical care unit has increased stress from the constant noise and light levels. What nursing intervention best attenuates these sources of stress?
- A. Need for constant observation and evaluation
- B. Dimming lights during the night
- C. Frequent nursing group rounds for all patients
- D. Use of tile floors for ease in cleaning
Correct Answer: B
Rationale: The correct answer is B: Dimming lights during the night. This intervention helps reduce stress by creating a more calming environment, promoting rest and sleep. Constant observation (choice A) may increase stress due to lack of privacy. Frequent group rounds (choice C) may disrupt rest. Use of tile floors (choice D) is unrelated to addressing noise and light stress.
Which of the following statements describes the core conc ept of the synergy model of practice?
- A. All nurses must be certified in order to have the synerg y model implemented.
- B. Family members must be included in daily interdisciplaibnirabr.cyo mro/teusnt ds.
- C. Nurses and physicians must work collaboratively and synergistically to influence care.
- D. Unique needs of patients and their families influence nursing competencies.
Correct Answer: D
Rationale: Rationale:
D is correct because the synergy model focuses on individualized care based on patients' unique needs. This model emphasizes tailoring nursing competencies to address these needs, promoting holistic care. A is incorrect as certification is not a requirement. B involves family inclusion but does not capture the core concept. C mentions collaboration but does not specifically address individualized care.
Which action by the nurse demonstrates cultural sensitivity in end-of-life care?
- A. Ensuring all patients receive the same standardized care.
- B. Avoiding discussions about death to prevent discomfort.
- C. Inquiring about specific cultural rituals and preferences.
- D. Advising families to follow hospital guidelines strictly.
Correct Answer: C
Rationale: The correct answer is C because inquiring about specific cultural rituals and preferences shows respect for the patient's cultural beliefs and values. By asking about these aspects, the nurse can provide care that aligns with the patient's cultural background, promoting comfort and understanding. This action also demonstrates a commitment to individualized care.
Choice A is incorrect because standardized care may not always be culturally appropriate. Choice B is incorrect as avoiding discussions about death can hinder effective communication and support. Choice D is incorrect as advising families to strictly follow hospital guidelines may overlook the importance of cultural considerations in end-of-life care.