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A patient in a critical care unit has increased stress from the constant noise and light levels. What nursing intervention best attenuates these sources of stress?
- A. Need for constant observation and evaluation
- B. Dimming lights during the night
- C. Frequent nursing group rounds for all patients
- D. Use of tile floors for ease in cleaning
Correct Answer: B
Rationale: The correct answer is B: Dimming lights during the night. This intervention helps reduce stress by creating a more calming environment, promoting rest and sleep. Constant observation (choice A) may increase stress due to lack of privacy. Frequent group rounds (choice C) may disrupt rest. Use of tile floors (choice D) is unrelated to addressing noise and light stress.
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Palliation care includes what goals? (Select all that apply.)
- A. Pain relief
- B. Nausea relief
- C. Psychological support
- D. Withdrawal of life-support interventions
Correct Answer: A
Rationale: The correct answer is A (Pain relief) because palliative care aims to provide comfort and improve the quality of life for individuals with serious illnesses. Pain relief is a crucial goal in palliative care to alleviate physical suffering. Nausea relief (B) is also commonly addressed in palliative care, but it is not a universal goal. Psychological support (C) is an important aspect of palliative care but is not always a primary goal. Withdrawal of life-support interventions (D) is not a goal of palliative care, as palliative care focuses on symptom management and improving quality of life, not hastening death.
When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?
- A. Zero balance the transducer.
- B. Activate the fast flush system.
- C. Notify the health care provider.
- D. Deflate and reinflate the PA balloon.
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.
The nurse aware that a shortage of organs exists knows that which statement is true?
- A. Anyone who is comfortable approaching the family sh ould discuss the option of organ donation.
- B. Brain death determination is required before organs ca n be retrieved for transplant.
- C. Donation of selected organs after cardiac death is ethically acceptable.
- D. Family members should consider withdrawing life supapboirbrt.c osmo /ttehsat t the patient can become an organ donor.
Correct Answer: B
Rationale: Rationale for Correct Answer (B - Brain death determination is required before organs can be retrieved for transplant):
1. Brain death determination is a medical necessity to ensure the organs are viable for transplant.
2. Organs must be retrieved promptly after brain death to maintain their functionality.
3. Brain death criteria ensure that the donor is truly deceased before organ retrieval.
Summary of Why Other Choices are Incorrect:
A: While discussing organ donation is important, comfort level is not the main factor in organ shortage awareness.
C: Donation after cardiac death is ethically acceptable, but it is not directly related to the need for brain death determination.
D: Withdrawing life support solely to become an organ donor is ethically questionable and not a necessary step in organ donation.
Her urine output for the past 2 hours totaled only 40 mL. She arrived from s urgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and he r blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusaiboirnb .coofm n/toesrtm al saline at 100 mL per hour. Her right atrial pressure through the subclavian cen tral line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider in creasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate fo r what part of the model?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: C
Rationale: The correct answer is C: Assessment. In the SBAR communication model, the nurse's information about the patient's history and vital signs falls under the Assessment component. This is because the nurse is providing a detailed evaluation of the patient's current condition based on objective data such as urine output, heart rate, blood pressure, and other key indicators. The nurse is analyzing the situation and forming a judgment that the patient is hypovolemic, indicating a fluid deficit. This assessment is crucial for informing further actions or interventions, such as increasing fluids or providing a fluid challenge.
Summary of other choices:
A: Situation - This choice would refer to a brief summary of the current situation without detailed analysis or interpretation.
B: Background - This choice would involve providing relevant background information about the patient, such as medical history or recent procedures, but not the current assessment of the patient's condition.
D: Recommendation - This choice would involve suggesting a course of action or treatment based on the assessment, which comes after
The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
- A. Check quickly for possible causes of the alarm that can be fixed.
- B. After troubleshooting, connect back to mechanical venti lator and reassess patient.
- C. Go to patient’s bedside.
- D. Manually ventilate the patient while getting respiratory therapist.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.