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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.
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The nurse is caring for a postoperative patient in the critica l care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands what facts about the PCA? (Select all that apply.)
- A. It is a safe and effective method for administering anal gesia.
- B. It has potentially fewer side effects than other routes of analgesic administration.
- C. It is an ideal method to provide critically ill patients so me control over their treatment.
- D. It does not work well without family assistance
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Patient-controlled analgesia (PCA) allows patients to self-administer pain medication within preset limits, promoting pain management.
2. PCA is considered safe and effective as it provides better pain control, reduces the risk of overdose, and allows for individualized dosing.
3. Healthcare providers can monitor and adjust the PCA settings as needed to ensure optimal pain relief.
4. Studies have shown that PCA is a preferred method for postoperative pain management due to its efficacy and safety profile.
5. Overall, PCA is a reliable and beneficial approach to analgesia administration in postoperative patients.
Summary of why other choices are incorrect:
B: While PCA may have fewer side effects compared to some routes, this is not a defining characteristic of PCA.
C: While patients do have some control over their treatment with PCA, the primary focus is on pain management rather than giving control to critically ill patients.
D: PCA can be used effectively without family
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
- A. A patient with no pedal pulses.
- B. A patient with an open femur fracture.
- C. A patient with bleeding facial lacerations.
- D. A patient with paradoxical chest movements.
Correct Answer: D
Rationale: The correct answer is D: A patient with paradoxical chest movements. This indicates flail chest, a life-threatening condition where a segment of the chest wall moves independently from the rest.
1. Flail chest can lead to respiratory compromise and potential respiratory failure.
2. Immediate intervention is needed to stabilize the chest wall and support breathing.
3. Without prompt treatment, the patient can develop hypoxia and potentially progress to cardiac arrest.
Summary:
- Choice A: No pedal pulses may indicate vascular compromise but does not pose an immediate threat to life.
- Choice B: Open femur fracture requires urgent treatment but does not have the same immediate life-threatening implications as flail chest.
- Choice C: Bleeding facial lacerations can be managed after addressing more critical injuries like flail chest.
The nurse is concerned that the patient will pull out the en dotracheal tube. As part of the nursing management, the nurse should obtain an order for what intervention?
- A. A Posey-type vest
- B. A higher dosage of lorazepam
- C. Propofol
- D. Soft wrist restraints
Correct Answer: A
Rationale: The correct answer is A. A Posey-type vest is a restraint designed to prevent patients from pulling out medical devices like endotracheal tubes, ensuring their safety. It is a less restrictive option compared to wrist restraints and sedatives (B and C), which can have adverse effects and may not directly address the concern of tube removal. Using a Posey-type vest promotes patient autonomy by allowing some movement while still providing the necessary protection.
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.
Which of the following nursing activities demonstrates im plementation of the AACN Standards of Professional Performance? (Select all that ap ply.)
- A. Attending a meeting of the local chapter of the Americ an Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught
- B. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family
- C. Participating on the unit’s nurse practice council
- D. Posting an article from Critical Care Nurse on manage ment of venous thromboembolism for your colleagues to read
Correct Answer: C
Rationale: The correct answer is C because participating on the unit's nurse practice council demonstrates adherence to the AACN Standards of Professional Performance, specifically the standard related to quality of practice. By actively engaging in the nurse practice council, the nurse contributes to the development and implementation of policies and procedures that promote quality patient care. This activity also involves collaboration, leadership, and advocacy, which are essential components of professional nursing practice.
The other choices are incorrect because:
A: Attending a meeting and receiving continuing education on sepsis is important for professional development but does not directly align with the AACN Standards of Professional Performance.
B: Collaborating with a pastoral services colleague is essential for holistic patient care but does not specifically address the standards set by the AACN.
D: Posting an article for colleagues to read is beneficial for knowledge sharing but does not directly demonstrate adherence to the AACN Standards of Professional Performance.