A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient?
- A. Insist that only a female doctor be assigned to this patient.
- B. Ensure that no pork products are included in the patients diet.
- C. Ensure that direct eye contact is not made with the patients husband.
- D. Ask the patients husband what religious and cultural preferences should be considered in the patients care.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates respect for the patient's autonomy and individual preferences. By asking the patient's husband about religious and cultural preferences, the nurse acknowledges the importance of involving the family in decision-making and shows sensitivity to the patient's beliefs. This approach promotes cultural competence and patient-centered care.
Choice A is incorrect because insisting on a female doctor may not align with the patient's preferences and may limit the available medical staff. Choice B is also incorrect as dietary restrictions are not necessarily the most pressing issue in this scenario. Choice C is incorrect as it assumes a cultural practice without verifying the patient's specific preferences and may not be necessary or appropriate in this context.
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The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next?
- A. Explain ICU visitation policies and encourage family visits.
- B. Immediately take the family members to the patient’s bedside.
- C. Describe the patient’s injuries and the care that is being provided.
- D. Invite the family to participate in a multidisciplinary care conference.
Correct Answer: A
Rationale: The correct answer is A: Explain ICU visitation policies and encourage family visits. This is the best course of action because it prioritizes the needs of the family members by providing them with information on visitation policies and encouraging them to visit the patient. This helps establish communication, support, and involvement in the patient's care. It also respects the family's emotional needs during a challenging time.
Choices B, C, and D are incorrect:
B: Immediately taking the family members to the patient's bedside may overwhelm them and disrupt the patient's care.
C: Describing the patient's injuries and care being provided should be done in a more controlled environment to ensure the family's understanding and emotional readiness.
D: Inviting the family to a multidisciplinary care conference may be premature without first addressing their immediate concerns and providing support.
A 20-year-old patient arrives in the emergency department (ED) several hours after taking 25 to 30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
- A. Give N-acetylcysteine (Mucomyst).
- B. Discuss the use of chelation therapy.
- C. Start oxygen using a non-rebreather mask.
- D. Have the patient drink large amounts of water.
Correct Answer: A
Rationale: The correct answer is A: Give N-acetylcysteine (Mucomyst). N-acetylcysteine is the antidote for acetaminophen overdose. It helps replenish glutathione, which is depleted by acetaminophen metabolism. This prevents liver damage. Choice B, chelation therapy, is not indicated for acetaminophen overdose. Choice C, oxygen therapy, is not directly related to acetaminophen overdose treatment. Choice D, drinking water, will not address the overdose and may not be safe in high doses. Therefore, the best course of action is to administer N-acetylcysteine to prevent liver damage in acetaminophen overdose.
Which of the following is (are) official journal(s) of the A merican Association of Critical-Care Nurses? (Select all that apply.)
- A. American Journal of Critical Care
- B. Critical Care Clinics of North America
- C. Critical Care Nurse
- D. Critical Care Nursing Quarterly
Correct Answer: A
Rationale: Step-by-step rationale:
1. The American Association of Critical-Care Nurses (AACN) publishes the American Journal of Critical Care (AJCC).
2. The AJCC is a peer-reviewed journal that covers critical care nursing practice, research, and education.
3. The content in AJCC aligns with AACN's mission and standards for critical care nursing.
4. Hence, AJCC is an official journal of AACN.
Summary of other choices:
- B: Critical Care Clinics of North America - Not an official journal of AACN.
- C: Critical Care Nurse - Not an official journal of AACN.
- D: Critical Care Nursing Quarterly - Not an official journal of AACN.
One of the strategies shown to reduce perception of stress in critically ill patients and their families is support of spirituality. What nursing action is most clearly supportive of the patients spirituality?
- A. Referring patients to the Catholic chaplain
- B. Providing prayer booklets to patients and families
- C. Asking about beliefs about the universe
- D. Avoiding discussing religion with those of other faiths
Correct Answer: C
Rationale: The correct answer is C because asking about beliefs about the universe allows the nurse to understand the patient's spiritual needs and provide appropriate support. This action shows respect for the patient's beliefs and can help establish a connection between the patient and the nurse. Referring patients to a specific religious figure (choice A) may not align with the patient's beliefs. Providing prayer booklets (choice B) assumes the patient's belief system and may not be helpful. Avoiding discussing religion (choice D) can hinder the nurse-patient relationship and overlook potential sources of support for the patient.
The nurse is caring for a patient who has an intra-aortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions?
- A. Ensure that the IABP console has been turned off.
- B. Assess the patient's vital signs and orientation.
- C. Notify the healthcare provider of the IABP malfunction.
- D. Obtain supplies for insertion of a new IABP catheter.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Ensuring the IABP console is turned off is crucial to prevent further complications and stop potential harm to the patient.
2. By turning off the IABP console, the nurse can halt the pumping action, allowing assessment of the situation without interference.
3. This action takes priority over other steps as it addresses the immediate issue of blood backing up into the IABP catheter.
4. Once the console is turned off, the nurse can proceed with assessing the patient's vital signs, notifying the healthcare provider, and obtaining supplies if needed.
Summary of Incorrect Choices:
- Option B: Assessing vital signs and orientation is important, but addressing the malfunction of the IABP takes precedence to prevent harm.
- Option C: Notifying the healthcare provider is necessary, but first, the immediate issue of blood backing up into the catheter must be addressed.
- Option D: Obtaining supplies for a new catheter is premature without first addressing