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A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
- A. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- B. Cluster nursing activities so that the patient has uninterrupted rest periods.
- C. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
- D. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.
Correct Answer: B
Rationale: The correct answer is B: Cluster nursing activities so that the patient has uninterrupted rest periods.
Rationale:
1. Clustering nursing activities allows for uninterrupted rest periods, essential for improving sleep quality and addressing disturbed sensory perception.
2. Administering sedatives or opioids (Option A) can lead to drug dependence, tolerance, and adverse effects in older adults.
3. Silencing alarms (Option C) compromises patient safety by impeding timely monitoring and response to critical events.
4. Eliminating assessments (Option D) between 0100 and 0600 disregards the necessity of monitoring vital signs and assessing patient condition around the clock.
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The nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first?
- A. Adherence to procedures by nursing staff
- B. Clarity of interdisciplinary communication
- C. Number of new employees on the unit
- D. Changes in administration procedures
Correct Answer: A
Rationale: The correct answer is A: Adherence to procedures by nursing staff. This should be evaluated first because medication errors are often caused by human factors such as staff not following proper procedures. By assessing adherence, the root cause of errors can be identified and addressed.
Choice B: Clarity of interdisciplinary communication may contribute to errors but doesn't directly address staff adherence to procedures.
Choice C: Number of new employees could be a factor, but focusing on adherence to procedures is more crucial.
Choice D: Changes in administration procedures may impact errors, but evaluating staff adherence is more immediate and directly related to errors.
The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
- A. Wear the brace over a T-shirt 23 hours per day.
- B. Dress with the brace over regular clothing.
- C. Shower with the brace directly against the skin.
- D. Remove the brace just before going to bed.
Correct Answer: A
Rationale: The correct answer is A because wearing the Milwaukee brace over a T-shirt ensures proper skin protection and ventilation. This helps prevent skin irritation and allows for comfortable wearing for long periods. Choice B may cause skin issues due to friction. Choice C is incorrect as moisture from showering can lead to skin problems. Choice D is incorrect as consistent wear is crucial for brace effectiveness.
When assessing the patient for hypoxemia, the nurse recognizes what as an early sign of the effect of hypoxemia on the cardiovascular system?
- A. Heart block
- B. Restlessness
- C. Tachycardia
- D. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. Hypoxemia results in decreased oxygen levels in the blood, stimulating the body to increase heart rate to improve oxygen delivery. Tachycardia is an early sign of the cardiovascular system compensating for hypoxemia. Heart block (A) is a disruption in the electrical conduction within the heart and is not directly related to hypoxemia. Restlessness (B) is a non-specific sign and can be caused by various factors. Tachypnea (D) is an increased respiratory rate, which is a response to hypoxemia but not a direct effect on the cardiovascular system.
When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is:
- A. Central venous pressure (CVP).
- B. Systemic vascular resistance (SVR).
- C. Pulmonary vascular resistance (PVR).
- D. Pulmonary artery wedge pressure (PAWP).
Correct Answer: D
Rationale: The correct answer is D: Pulmonary artery wedge pressure (PAWP). This is crucial in monitoring a patient with a large anterior wall myocardial infarction as it provides information on left ventricular function and fluid status. A high PAWP may indicate left ventricular failure or fluid overload, requiring immediate intervention.
A: Central venous pressure (CVP) is not as specific for assessing left ventricular function and may not provide accurate information in this scenario.
B: Systemic vascular resistance (SVR) is important in assessing systemic blood flow, but it may not directly indicate left ventricular function in this case.
C: Pulmonary vascular resistance (PVR) is more relevant in conditions affecting the pulmonary circulation and may not be as immediately informative in assessing left ventricular function in this context.
The nurse notes that a patient’s endotracheal tube (ET), which was at the 22 cm mark, is now at the 25 cm mark and the patient is anxious and restless. Which action should the nurse take next?
- A. Offer reassurance to the patient.
- B. Bag the patient at an FIO2 of 100%.
- C. Listen to the patient’s breath sounds.
- D. Notify the patient’s health care provider.
Correct Answer: C
Rationale: The correct answer is C: Listen to the patient’s breath sounds. Moving from 22 cm to 25 cm may indicate ET tube migration. Checking breath sounds can confirm proper tube placement. A may not address the underlying issue. B could worsen the situation if the tube is misplaced. D is not urgent compared to assessing airway integrity.