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A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?
- A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
- B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
- C. Encourage the family to request that the physician evaluate the patients pain control.
- D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C
Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.
Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.
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The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
- A. Activate the rapid response team.
- B. Provide reassurance to the patient.
- C. Call the health care provider to reinsert the tube.
- D. Manually ventilate the patient with 100% oxygen.
Correct Answer: D
Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.
A patient receiving palliative care for advanced cancer reports fatigue and loss of appetite. Which intervention should the nurse prioritize?
- A. Encourage the patient to eat small, frequent meals.
- B. Administer prescribed appetite stimulants.
- C. Provide rest periods to reduce fatigue.
- D. Discuss the benefits of parenteral nutrition.
Correct Answer: C
Rationale: The correct answer is C: Provide rest periods to reduce fatigue. Prioritizing rest periods can help alleviate fatigue, a common symptom in patients with advanced cancer. Encouraging small, frequent meals (choice A) may not be effective if the patient has no appetite. Administering appetite stimulants (choice B) may not address the root cause of fatigue. Discussing parenteral nutrition (choice D) is not the priority as it does not directly address the fatigue and loss of appetite reported by the patient. Rest is essential for symptom management and overall well-being in palliative care.
Intrapulmonary shunting refers to what outcome?
- A. Alveoli that are not perfused.
- B. Blood that is shunted from the left side of the heart to t he right and causes heart failure.
- C. Blood that is shunted from the right side of the heart to the left without oxygenation.
- D. Shunting of blood supply to only one lung.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Intrapulmonary shunting refers to blood bypassing the normal oxygenation process in the lungs.
2. Choice C describes blood being shunted from the right side of the heart (deoxygenated blood) to the left side without oxygenation, leading to systemic circulation without oxygenation.
3. Choices A, B, and D do not accurately describe intrapulmonary shunting as they focus on other concepts like alveolar perfusion, heart failure, and unilateral lung blood supply, respectively.
An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
- A. Antacids.
- B. Tricyclic antidepressants.
- C. Nonsteroidal anti-inflammatory agents.
- D. Insulin.
Correct Answer: B
Rationale: The correct answer is B: Tricyclic antidepressants. Tricyclic antidepressants can cause anticholinergic effects, including urinary retention, especially in the elderly. Morphine sulfate can also contribute to urinary retention. Antacids (A) and nonsteroidal anti-inflammatory agents (C) are not known to cause urinary retention. Insulin (D) does not pose a risk for urinary retention in this scenario.
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.