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A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
- A. Auscultate heart sounds.
- B. Palpate peripheral pulses.
- C. Auscultate breath sounds.
- D. Check pupil reaction to light.
Correct Answer: C
Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention.
A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario.
B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications.
D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.
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The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should
- A. draw blood from the left arm.
- B. take blood pressures from the left arm.
- C. start a new intravenous line in the left lower arm.
- D. auscultate the left arm for a bruit and palpate for a thrill.
Correct Answer: D
Rationale: The correct answer is D because after arteriovenous fistula implantation, it is essential to assess for the presence of a bruit (audible sound caused by turbulent blood flow) and thrill (vibratory sensation) in the access site, which indicates proper functioning of the fistula. This assessment ensures that blood is flowing adequately through the newly created access for dialysis or other procedures. Drawing blood or taking blood pressures from the fistula arm can lead to complications such as clot formation or damage to the fistula. Starting a new IV line in the same arm is contraindicated to avoid compromising the newly created fistula. Thus, auscultating for a bruit and palpating for a thrill are the appropriate nursing actions in this scenario.
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.
Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
- A. Provide postmortem care to the patient.
- B. Encourage the family members to talk with and reassure the patient.
- C. Determine how frequently physical assessments are needed for the patient.
- D. Teach family members about commonly occurring signs of approaching death.
Correct Answer: A
Rationale: The correct answer is A because providing postmortem care to a dying patient is a task that can be safely delegated to an LPN/LVN. This includes tasks such as preparing the body, cleaning, and positioning after death. LPNs/LVNs are trained and competent in performing these duties under the supervision of a registered nurse or physician.
Choices B, C, and D are incorrect because they involve critical thinking, assessment, and teaching skills that are typically within the scope of practice of a registered nurse. Encouraging family members to talk with the patient, determining assessment frequency, and educating about signs of approaching death require a higher level of nursing judgment and expertise, which is beyond the scope of an LPN/LVN's role.
Which statement is a likely response from someone who h as survived a stay in the critical care unit?
- A. “I don’t remember much about being in the ICU, but if I had to be treated there again, it would be okay. I’m glad I can see my grandchildren again.”
- B. “If I get that sick again, do not take me to the hospital. I would rather die than go through having a breathing tube put in again.”
- C. “My family is thrilled that I am home. I know I need some extra attention, but my children have rearranged their schedules to help me ou t.”
- D. “Since I have been transferred out of the ICU, I cannot get enough to eat. They didn’t let me eat in the ICU, so I’m making up for it no w.”
Correct Answer: A
Rationale: Rationale: Choice A is the correct answer because it reflects a positive attitude towards potential future treatments in the critical care unit and gratitude for being able to see family again. The survivor acknowledges the past experience but remains optimistic.
Summary:
- Choice B is incorrect as it shows a strong aversion to hospital care, indicating a preference for death over treatment.
- Choice C is incorrect as it focuses on the family's reaction and not the survivor's personal experience or perspective.
- Choice D is incorrect as it highlights a trivial aspect (eating) rather than reflecting on the ICU experience or future treatments.
What is the most important outcome of effective communi cation?
- A. Demonstrating caring practices to family members.
- B. Ensuring that patient teaching is provided
- C. Meeting the diversity needs of patients.
- D. Reducing patient errors.
Correct Answer: D
Rationale: The correct answer is D because reducing patient errors is the most important outcome of effective communication in healthcare. Clear and accurate communication among healthcare providers and patients can prevent misunderstandings, leading to fewer errors in diagnosis, treatment, and medication administration. This ultimately improves patient safety and outcomes.
A: Demonstrating caring practices to family members is important but not the most crucial outcome of effective communication in healthcare.
B: Ensuring that patient teaching is provided is essential, but patient safety through error reduction takes precedence.
C: Meeting the diversity needs of patients is crucial for patient-centered care, but error reduction directly impacts patient safety, making it more critical.