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A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make?
- A. Provide the patient with a bath immediately following his first 90-minute REM sleep cycle.
- B. Increase the patients pain medication.
- C. Provide the patient with 5 minutes of effleurage and then minimize disruptions.
- D. Monitor the patients brain waves by polysomnography to determine his sleep pattern.
Correct Answer: C
Rationale: Rationale:
C: Providing the patient with 5 minutes of effleurage (gentle massage) and minimizing disruptions is the most helpful intervention. Effleurage can help reduce anxiety and promote relaxation, improving sleep quality. Minimizing disruptions creates a conducive environment for sleep.
A: Providing a bath after REM sleep may disrupt the patient's sleep cycle, worsening anxiety.
B: Increasing pain medication may not address the root cause of anxiety and could lead to dependency or side effects.
D: Monitoring brain waves with polysomnography is an invasive procedure not typically indicated for managing anxiety-related sleep issues.
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The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring th e patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is m ost important for the nurse to complete?
- A. Document a pulmonary artery catheter occlusion press ure.
- B. Zero reference the transducer system at the phlebostatic axis.
- C. Inflate the pulmonary artery catheter balloon with 1 m L air.
- D. Inject 10 mL of 0.9% normal saline into the proximal port.
Correct Answer: B
Rationale: The correct answer is B: Zero reference the transducer system at the phlebostatic axis. This is the most important action before obtaining a cardiac output because zero referencing ensures accurate pressure readings. The phlebostatic axis is the level of the atria when the patient is supine, and zeroing at this point minimizes errors in pressure measurements.
Choice A is incorrect because documenting a pulmonary artery catheter occlusion pressure is not the priority at this stage. Choice C is incorrect as inflating the balloon with air should be done after zero referencing. Choice D is incorrect as injecting normal saline into the port is not necessary before zero referencing.
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
- A. Glasgow Coma Scale score of 3
- B. Train-of-four yields two twitches
- C. Bispectral index of 60
- D. CAM-ICU positive
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation.
A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade.
C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level.
D: CAM-ICU assesses delirium, not neuromuscular blockade.
The patient has just returned from having an arteriovenous fistula placed. The patient asks, “When will they be able to use this and take this other catheter out?” The nurse should reply,
- A. “It can be used immediately, so the catheter can come out anytime.”
- B. “It will take 2 to 4 weeks to heal before it can be used.”
- C. “The fistula will be usable in about 4 to 6 weeks.”
- D. “The fistula was made using graft material, so it depends on the manufacturer.”
Correct Answer: C
Rationale: The correct answer is C: “The fistula will be usable in about 4 to 6 weeks.” The rationale for this is that an arteriovenous fistula typically requires 4 to 6 weeks to mature and be ready for use. During this time, the fistula develops the necessary blood flow for efficient dialysis.
Choice A is incorrect because immediate use of the fistula is not recommended as it needs time to mature. Choice B is incorrect as it underestimates the time needed for the fistula to heal and mature. Choice D is incorrect as the usability of the fistula is not dependent on the manufacturer but rather on the patient's individual healing process.
Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery?
- A. Aspirin
- B. Embolectomy
- C. Heparin
- D. Thrombolytics
Correct Answer: D
Rationale: The correct answer is D: Thrombolytics. Thrombolytics are medications that can dissolve blood clots, making them effective in treating a thrombus lodged in the pulmonary artery. They work by activating the body's natural clot-dissolving system. Aspirin (A) is an antiplatelet drug and may prevent further clot formation but cannot dissolve an existing thrombus. Embolectomy (B) is a surgical procedure to remove a clot and is invasive, usually reserved for cases where thrombolytics are contraindicated. Heparin (C) is an anticoagulant that prevents clot formation but does not dissolve existing clots like thrombolytics do.
Which therapeutic interventions may be withdrawn or withabhirebl.dco mfr/otemst the terminally ill client? (Select all that apply.)
- A. Antibiotics
- B. Dialysis
- C. Nutrition
- D. Pain medications
Correct Answer: B
Rationale: The correct answer is B: Dialysis. In the context of terminally ill clients, withdrawing dialysis is appropriate as it can be burdensome without providing significant benefit towards the end of life. Dialysis does not cure terminal conditions and can prolong suffering unnecessarily.
Antibiotics (A) may be necessary for managing infections in terminally ill clients. Nutrition (C) is important for comfort and quality of life. Pain medications (D) are essential for managing pain and should not be withdrawn unless no longer beneficial or requested by the patient.