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The nurse wishes to enhance sleep cycles in her critically ill patient. Research has shown that which nursing action improves sleep in critically ill patients?
- A. Repositioning every 2 hours
- B. Hypnotic medications
- C. Five-minute back effleurage
- D. Adequate pain control
Correct Answer: D
Rationale: The correct answer is D: Adequate pain control. Pain can significantly disrupt sleep in critically ill patients. By ensuring adequate pain control, the nurse can help improve the patient's ability to rest and sleep. This intervention targets a key factor affecting sleep cycles in critically ill patients. Repositioning every 2 hours (A) may help prevent pressure ulcers but does not directly address sleep improvement. Hypnotic medications (B) may have adverse effects and are not recommended as a first-line intervention. Five-minute back effleurage (C) may provide temporary relaxation but is not as effective as adequate pain control in improving sleep quality.
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The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?
- A. Question the type and quantity of foods eaten in a typical day.
- B. Encourage giving two additional snacks each day to the child.
- C. Recommend a daily intake of at least four glasses of whole milk.
- D. Assess for signs of poor nutrition, such as a pale appearance.
Correct Answer: A
Rationale: The correct answer is A: Question the type and quantity of foods eaten in a typical day. When a child's weight is in the 95th percentile for their height, it indicates possible overweight or obesity. To address this, the nurse should assess the child's dietary habits to identify any unhealthy eating patterns contributing to excess weight. By questioning the type and quantity of foods eaten, the nurse can provide appropriate guidance on nutrition and healthy eating habits.
Summary:
B: Encouraging additional snacks may further contribute to weight gain and is not recommended without knowing the current eating habits.
C: Recommending a high intake of whole milk may increase calorie intake and potentially worsen the weight concern.
D: Assessing for signs of poor nutrition, such as a pale appearance, is important but not directly addressing the weight concern in this scenario.
The nurse is caring for a mechanically ventilated patient an d responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarma, btihrbe.c nomu/rtesset assesses for which of the following? (Select all that apply.)
- A. Coughing or attempting to talk
- B. Disconnection from the ventilator
- C. Kinks in the ventilator tubing
- D. Need for suctioning
Correct Answer: B
Rationale: The correct answer is B: Disconnection from the ventilator. This is the correct choice because a high inspiratory pressure alarm can indicate a disconnection, leading to inadequate ventilation and increased pressure in the circuit. This can be a life-threatening situation that requires immediate attention.
Explanation of why other choices are incorrect:
A: Coughing or attempting to talk - While coughing or talking may affect the patient's ability to ventilate properly, it is not directly related to the high inspiratory pressure alarm.
C: Kinks in the ventilator tubing - Kinks in the tubing may cause increased resistance to airflow, but they are more likely to trigger a low pressure alarm rather than a high inspiratory pressure alarm.
D: Need for suctioning - Suctioning may be necessary for airway clearance, but it is not directly related to the high inspiratory pressure alarm.
Which statement reflects adherence to current recommendations concerning open visitation policies?
- A. Allowing animals on the unit; however, these can only be “therapy” animals through the hospital’s pet therapy program.
- B. Allowing family visitation throughout the day except a t change of shift and during rounds.
- C. Determining, in collaboration with the patient and famaiblyirb, .cwomho/te csta n visit and when.
- D. Permitting open visitation by adults 18 years of age and older; limit visits of children to 1 hour.
Correct Answer: C
Rationale: The correct answer is C because it reflects patient-centered care by involving patients and families in decision-making. Collaborating with them on visitation preferences promotes a supportive environment. Choice A restricts animal visitation, not addressing human visitors. Choice B limits visitation during specific times, not individualized. Choice D imposes restrictions based on age, not on patient/family preferences. Therefore, Choice C is the most aligned with current recommendations for open visitation policies.
A patient in the ICU has recently been diagnosed with diabetes mellitus. Before being discharged, this patient will require detailed instructions on how to manage her diet, how to self-inject insulin, and how to handle future diabetic emergencies. Which nurse competency is most needed in this situation?
- A. Clinical judgment
- B. Advocacy and moral agency
- C. Caring practices
- D. Facilitation of learning
Correct Answer: D
Rationale: The correct answer is D: Facilitation of learning. In this scenario, the nurse needs to effectively educate the patient on managing her diet, insulin injections, and handling emergencies. Facilitation of learning involves assessing the patient's learning needs, providing relevant information, demonstrating skills, and evaluating understanding. This competency is crucial for promoting patient education and empowerment in managing their condition.
A: Clinical judgment involves making decisions based on assessment data, which is important but not the primary focus in this situation.
B: Advocacy and moral agency involve standing up for patients' rights and values, which is important but not as directly relevant to the patient's education needs.
C: Caring practices involve showing empathy and compassion, which are essential but not the main competency required for educational purposes in this case.
The nurse is managing a donor patient six hours prior to th e scheduled harvesting of the patient’s organs. Which assessment finding requires imme diate action by the nurse?
- A. Morning serum blood glucose of 128 mg/dL
- B. pH 7.30; PaCO 38 mm Hg; HCO 16 mEq/L 2 3
- C. Pulmonary artery temperature of 97.8° F
- D. Central venous pressure of 8 mm Hg
Correct Answer: B
Rationale: The correct answer is B. The patient's pH of 7.30 indicates acidosis, PaCO2 of 38 mm Hg is low, and HCO3 of 16 mEq/L is also low, suggesting metabolic acidosis. This finding requires immediate action as untreated acidosis can lead to serious complications.
Choice A (morning serum blood glucose of 128 mg/dL) is within normal range and does not require immediate action.
Choice C (pulmonary artery temperature of 97.8°F) is a normal temperature and does not require immediate action.
Choice D (central venous pressure of 8 mm Hg) is within normal range and does not require immediate action.