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A patient with terminal cancer reports a sudden onset of severe pain. Which intervention should the nurse implement first?
- A. Assess the patient’s pain using a standardized pain scale.
- B. Administer a PRN dose of prescribed analgesic.
- C. Notify the healthcare provider about the patient’s pain.
- D. Reposition the patient to enhance comfort.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient’s pain using a standardized pain scale. The first step is to assess the severity and nature of the pain to determine the appropriate intervention. This allows the nurse to understand the pain intensity and characteristics, which guides the choice of analgesic and dosing. Administering analgesics (B) without proper assessment can lead to inappropriate treatment. Notifying the healthcare provider (C) is important but assessing the pain should come first. Repositioning the patient (D) may provide comfort but addressing the pain directly is the priority.
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Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best inter pretation of these results by the nurse?
- A. The catheter is not positioned correctly and should be removed.
- B. The catheter position increases the risk of ventricular daybisrbr.hcoymth/tmesti as.
- C. The distal tip of the catheter is in the appropriate position.
- D. The physician should be called to advance the catheter into the pulmonary artery.
Correct Answer: C
Rationale: The correct answer is C: The distal tip of the catheter is in the appropriate position.
Rationale:
1. The superior vena cava is a desirable location for a central venous catheter tip placement as it is close to the heart for rapid medication delivery.
2. Catheter tip in the superior vena cava allows for proper venous return and minimizes the risk of complications.
3. The nurse does not need to remove or adjust the catheter if the tip is in the superior vena cava.
4. Advancing the catheter into the pulmonary artery (option D) would be incorrect as it can lead to serious complications.
Incorrect choices:
A: Incorrect because placement in the superior vena cava is acceptable.
B: Incorrect as placement in the superior vena cava does not increase the risk of ventricular dysrhythmias.
D: Incorrect as advancing the catheter into the pulmonary artery is unnecessary and risky.
As part of the Synergy Model, the nurse has identified a patient characteristic of resiliency. What patient behavior demonstrates resiliency?
- A. Dysfunctional grieving behaviors after receiving bad news
- B. Developing a list of questions for the physician
- C. Denial of any possible negative outcomes for a procedure
- D. Assigning blame to others for undesired outcomes of illness
Correct Answer: B
Rationale: The correct answer is B because developing a list of questions for the physician shows active engagement in their healthcare, seeking information, and taking control of their situation, which are characteristics of resiliency. This behavior indicates the patient's willingness to understand and cope with their health condition. Choices A, C, and D are incorrect as they demonstrate maladaptive coping mechanisms such as dysfunctional grieving, denial, and blame assignment, which are not indicative of resiliency. Resiliency involves adaptability, problem-solving, and seeking support, which are better exemplified by choice B.
Which nursing interventions would best support the family of a critically ill patient?
- A. Encouraging family members to stay all night in case t he patient needs them.
- B. Giving a condition update each morning and whenever changes occur.
- C. Limiting visitation from children into the critical care u nit.
- D. Providing beverages and snacks in the waiting room.
Correct Answer: B
Rationale: The correct answer is B because giving regular condition updates promotes transparency and communication, reducing anxiety for the family. This intervention helps them stay informed and involved in the patient's care. Choice A may lead to caregiver fatigue and is not sustainable. Choice C limits family support and may increase stress. Choice D focuses on comfort but does not address the family's need for information.
The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient care?
- A. Determine the patient’s wishes regarding end-of-life care.
- B. Emphasize the importance of addressing any family issues.
- C. Discuss the normal grief process with the patient and family.
- D. Encourage the patient to talk about any fears or unresolved issues.
Correct Answer: A
Rationale: The correct answer is A because determining the patient's wishes regarding end-of-life care is crucial in providing patient-centered care and ensuring that the patient's preferences are respected. By understanding the patient's preferences, healthcare providers can tailor the care plan to align with the patient's values and goals. This helps in promoting autonomy, dignity, and quality of life for the patient.
Choices B, C, and D are incorrect because although addressing family issues, discussing grief, and encouraging the patient to express fears are important aspects of caring for a terminally ill patient, they are not the first action that should be completed. Prioritizing the patient's wishes ensures that the care plan is centered around the patient's needs and preferences, which is essential in providing holistic and patient-centered care.
A 10-year-old female patient in ICU receiving chemotherapy has requested that her dog be allowed to visit her. She is currently sharing a room with another patient. The nurse knows that the hospital does allow for pet visits with owners, but has strict guidelines. Which of the following scenarios is most likely to be permitted?
- A. The girls father may bring the dog in on a leash for a 20-minute visit.
- B. The girls sister may bring the dog in with a shirt on (to prevent shedding) for an overnight stay.
- C. The girls mother may bring the dog in on a leash for a visit as long as he has had all his vaccinations.
- D. The dog may be brought in for a brief visit once the girl is moved to a private room.
Correct Answer: A
Rationale: The correct answer is A because it follows the hospital's guidelines for pet visits. It allows the dog to be brought in on a leash, which ensures control and safety during the visit. The 20-minute duration is appropriate to limit potential stress on the patient and other individuals in the room. Additionally, having the father bring the dog in maintains consistency with the hospital's policy of pet visits with owners.
Choices B, C, and D are incorrect because they do not adhere to the hospital's guidelines. Choice B allows for an overnight stay, which is typically not permitted due to potential disruptions and hygiene concerns. Choice C mentions vaccinations but overlooks other important factors like leash control and visit duration. Choice D suggests waiting until the girl is moved to a private room, which may not align with the hospital's policy of allowing pet visits with owners.