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A patient has a nursing diagnosis of disturbed sleep pattern related to difficulty maintaining sleep state. Which of the following actions should the nurse include in the plan of care?
- A. Discontinue assessments during the night to allow uninterrupted sleep.
- B. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- C. Silence monitor alarms to allow 30- to 40-minute rest periods.
- D. Cluster nursing activities so that the patient has uninterrupted rest periods.
Correct Answer: D
Rationale: Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.
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The nurse notes thick, white respiratory secretions from a patient who is receiving mechanical ventilation. Which of the following interventions will be most effective in resolving this problem?
- A. Suction the patient every hour.
- B. Reposition the patient every 2 hours.
- C. Add additional water to the patient's enteral feedings.
- D. Instill 5 ml of sterile saline into the endotracheal tube (ET) before suctioning.
Correct Answer: C
Rationale: Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.
The nurse is caring for an older-adult patient who has stabilized after being in the intensive care unit (ICU) for a week and is preparing for transfer to the step-down unit when the nurse notices that the patient has new onset confusion. Which of the following actions should the nurse implement?
- A. Inform the receiving nurse and then transfer the patient.
- B. Notify the health care provider and postpone the transfer.
- C. Administer PRN lorazepam and cancel the transfer.
- D. Obtain an order for restraints as needed and transfer the patient.
Correct Answer: A
Rationale: The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation with sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.
The charge nurse is mentoring a new RN staff member providing care to a patient receiving mechanical ventilation. Which of the following actions by the new RN indicates the need for more education?
- A. The RN increases the FIO2 up to 100%.
- B. The RN secures a bite block in place using adhesive tape.
- C. The RN positions the patient with the head of bed at 10 degrees.
- D. The RN asks for assistance to turn the patient to the prone position.
Correct Answer: C
Rationale: The head of the patient's bed should be positioned at 30-45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate.
The nurse is preparing to assist with the insertion of a pulmonary artery catheter in a patient. Which of the following actions will the nurse implement?
- A. Check cardiac enzymes before insertion.
- B. Auscultate heart sounds during insertion.
- C. Place the patient on NPO status before the procedure.
- D. Attach cardiac monitoring leads before the procedure.
Correct Answer: D
Rationale: Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anaesthesia, and the patient will not need to be NPO. Changes in cardiac enzymes or heart sounds are not expected during pulmonary artery catheter insertion.
The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which of the following patient assessments indicates that the weaning protocol should be discontinued?
- A. The patient heart rate is 98 beats/minute.
- B. The patient's oxygen saturation is 93%.
- C. The patient respiratory rate is 32 breaths/minute.
- D. The patient's spontaneous tidal volume is 500 mL.
Correct Answer: C
Rationale: A respiratory rate of 32 breaths/minute indicates respiratory distress and suggests that the patient is not tolerating the weaning process, necessitating discontinuation of the weaning protocol. A heart rate of 98 beats/minute, oxygen saturation of 93%, and spontaneous tidal volume of 500 mL are within acceptable ranges for weaning.