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During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal pulse is absent and the leg is swollen. Which action will the nurse take next?
- A. Send blood to the lab for a complete blood count.
- B. Assess further for a cause of the decreased circulation.
- C. Finish the airway, breathing, circulation, and disability survey.
- D. Start normal saline fluid infusion with a large-bore IV line.
Correct Answer: B
Rationale: The correct answer is B: Assess further for a cause of the decreased circulation. The nurse should prioritize assessing the cause of the absent left pedal pulse and leg swelling to address the severe leg trauma effectively. This step involves identifying potential vascular compromise or compartment syndrome, which are critical conditions requiring immediate intervention. Sending blood for a complete blood count (A) is not the priority in this situation. Finishing the primary survey (C) may delay addressing the circulation issue. Starting normal saline infusion (D) without addressing the circulation problem first could potentially worsen the condition. Therefore, assessing further for the cause of decreased circulation is the most appropriate next step to ensure timely and appropriate management of the patient's condition.
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What is the main purpose of certification for critical care n ursing?
- A. To assure the consumer that critical nurses will not make a mistake.
- B. To help prepare the critical care nurse for graduate sch ool.
- C. To assist in promoting magnet status for a facility.
- D. To validate a nurse’s knowledge of critical care nursing
Correct Answer: D
Rationale: The correct answer is D: To validate a nurse’s knowledge of critical care nursing. Certification in critical care nursing validates a nurse's expertise and knowledge in this specialized area of nursing. It demonstrates that the nurse has met certain standards and competencies in critical care practice. This certification ensures that the nurse is well-equipped to provide high-quality care to critically ill patients.
A: To assure the consumer that critical nurses will not make a mistake - This choice is incorrect because certification does not guarantee that nurses will not make mistakes. It focuses on validating knowledge and skills rather than infallibility.
B: To help prepare the critical care nurse for graduate school - This choice is incorrect as certification is more focused on practice readiness rather than academic preparation.
C: To assist in promoting magnet status for a facility - This choice is incorrect as magnet status relates more to the overall excellence and quality of nursing care in a facility, not individual certification.
Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
- A. Provide postmortem care to the patient.
- B. Encourage the family members to talk with and reassure the patient.
- C. Determine how frequently physical assessments are needed for the patient.
- D. Teach family members about commonly occurring signs of approaching death.
Correct Answer: A
Rationale: The correct answer is A because providing postmortem care to a dying patient is a task that can be safely delegated to an LPN/LVN. This includes tasks such as preparing the body, cleaning, and positioning after death. LPNs/LVNs are trained and competent in performing these duties under the supervision of a registered nurse or physician.
Choices B, C, and D are incorrect because they involve critical thinking, assessment, and teaching skills that are typically within the scope of practice of a registered nurse. Encouraging family members to talk with the patient, determining assessment frequency, and educating about signs of approaching death require a higher level of nursing judgment and expertise, which is beyond the scope of an LPN/LVN's role.
A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?
- A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
- B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
- C. Encourage the family to request that the physician evaluate the patients pain control.
- D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C
Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.
Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.
The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
- A. Heart rate is 58 beats/minute.
- B. Mean arterial pressure (MAP) is 56 mm Hg.
- C. Systemic vascular resistance (SVR) is elevated.
- D. Pulmonary artery wedge pressure (PAWP) is low.
Correct Answer: B
Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.
The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice?
- A. Use of computerized records by the hospital
- B. Health Information Privacy and Portability Act (HIPPA)
- C. Lack of knowledge about literature searches
- D. Strong collaborative relationships in the work setting
Correct Answer: C
Rationale: Rationale:
The correct answer is C because lack of knowledge about literature searches hinders the ability to find and utilize evidence-based practice guidelines. Nurses need to be skilled in conducting literature searches to access relevant research. Choices A, B, and D are incorrect as they do not directly impede the implementation of evidence-based practice in the critical care unit.