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Family assessment is essential in order to meet family nee ds. Which of the following must be assessed first to assist the nurse in providing family-centered care?
- A. Assessment of patient and family’s developmental stag es and needs
- B. Description of the patient’s home environment
- C. Identification of immediate family, extended family, a nd decision makers
- D. Observation and assessment of how family members fu nction with each other
Correct Answer: A
Rationale: The correct answer is A because assessing the patient and family's developmental stages and needs is crucial in understanding their current situation and determining the appropriate care plan. By assessing developmental stages, the nurse can tailor interventions to meet the family's specific needs. This assessment also helps in identifying potential challenges or areas requiring support.
Choice B is incorrect as it focuses solely on the physical environment and does not address the family's developmental stages and needs.
Choice C is incorrect as it emphasizes identifying family members without considering the importance of understanding their developmental stages and needs in providing family-centered care.
Choice D is incorrect as it concentrates on family dynamics without directly addressing the crucial aspect of assessing developmental stages and needs for effective family-centered care.
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Which of the following devices is best suited to deliver 65 % oxygen to a patient who is spontaneously breathing?
- A. Face mask with non-rebreathing reservoir
- B. Low-flow nasal cannula
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask is the best choice for delivering 65% oxygen because it allows precise oxygen concentration delivery through adjustable venturi valves. This device ensures consistent oxygen levels even during variations in patient breathing patterns. Face mask with non-rebreathing reservoir (A) delivers higher oxygen concentrations, low-flow nasal cannula (B) is not suitable for precise oxygen delivery, and simple face mask (C) may not provide the desired oxygen concentration.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?
- A. “I’m going to contact the pharmacist to see if you can take this medication by mouth.”
- B. “This injection is being given to prevent blood clots fr om forming.”
- C. “This medication will dissolve any blood clots you migabhirtb .gcoemt./”te st
- D. “I will contact your primary care provide to discuss wh y you are getting this medication.” t
Correct Answer: B
Rationale: The correct answer is B: “This injection is being given to prevent blood clots from forming.” Enoxaparin is an anticoagulant used to prevent blood clots. It is administered through injection, not orally (A). Enoxaparin does not dissolve existing blood clots (C). Contacting the primary care provider to discuss the medication is not necessary in this scenario (D). The correct choice emphasizes the purpose of enoxaparin in preventing new blood clots.
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a healthcare provider. In which order should the nurse make the following statements?
- A. The patient needs to be evaluated immediately and may need intubation and mechanical ventilation.
- B. The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low.
- C. The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable.
- D. This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour.
Correct Answer: B
Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication.
Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom.
Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition.
Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process.
Summary:
- Choice A is incorrect as the recommendation should come after providing background, situation, and assessment.
- Choice C is incorrect as assessment details should precede the patient's critical condition.
- Choice D is incorrect as the situation should be explained before expressing concern.
The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety?
- A. Restlessness
- B. Verbalization
- C. Increased respiratory rate
- D. Glasgow Coma Scale score of 3
Correct Answer: A
Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.
A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should resultf rom these measures?
- A. Identification of incompetent practitioners
- B. Improvement in manners on the unit
- C. Increased staff retention
- D. Less discussion in front of patients and families
Correct Answer: C
Rationale: Rationale:
- Improved collaboration enhances job satisfaction and reduces burnout, leading to increased staff retention.
- Higher staff retention promotes continuity of care, improves team dynamics, and enhances patient outcomes.
Summary:
- A: Not directly related to collaboration, more about performance evaluation.
- B: Manners may improve, but not the most important effect of collaboration.
- D: Collaboration involves open communication, so less discussion in front of patients is not a positive outcome.