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Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
- A. Insert a large-bore orogastric tube.
- B. Assist with the intubation of the patient.
- C. Prepare a 60-mL syringe with saline.
- D. Give the first dose of activated charcoal.
Correct Answer: B
Rationale: The correct answer is B: Assist with the intubation of the patient. In this scenario, the patient is unconscious and has ingested a potentially harmful substance. Intubation is the first priority to maintain the patient's airway and ensure adequate oxygenation. This step is crucial in preventing aspiration of gastric contents and securing the patient's respiratory status. Inserting a large-bore orogastric tube (choice A) is not the priority as airway management takes precedence. Preparing a syringe with saline (choice C) is unnecessary at this stage. Giving the first dose of activated charcoal (choice D) should only be done after securing the airway to prevent aspiration.
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A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and
- A. The primary health care provider has approached the spouse regarding placement of a perma nent feeding tube. The spouse states that the patient never wanted to be kept alive by tub es and personally didn’t want what was being done. After holding a family conference with th e spouse, the medical team concurs and the feeding tube is not placed. What term would be used to describe this situation?
- B. Euthanasia
- C. Palliative care
- D. Withdrawal of life support
Correct Answer: E
Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes.
Step 2: The decision aligns with the principle of respecting patient autonomy.
Step 3: The term that best describes this situation is "Advance Directive."
Summary:
- A: Incorrect, as it involves actively ending the patient's life without their consent.
- B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering.
- C: Incorrect, as palliative care focuses on improving quality of life for the patient.
- D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.
The family of your critically ill patient tells you that they h ave not spoken with the physician in over 24 hours and they have some questions that they w ant clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which com petency of critical care nursing does this represent?
- A. Advocacy and moral agency in solving ethical issues
- B. Clinical judgment and clinical reasoning skills
- C. Collaboration with patients, families, and team membe rs
- D. Facilitation of learning for patients, families, and team members
Correct Answer: C
Rationale: The correct answer is C: Collaboration with patients, families, and team members. By addressing the family's concern about lack of communication with the physician and arranging a meeting between the intensivist and the family, the nurse is demonstrating collaboration skills in facilitating communication and ensuring the family's questions are addressed. This competency emphasizes the importance of working together with patients, families, and the healthcare team to provide optimal care.
Incorrect choices:
A: Advocacy and moral agency in solving ethical issues - While advocacy is important in nursing, in this scenario, the focus is on communication and collaboration rather than ethical issues.
B: Clinical judgment and clinical reasoning skills - Although these skills are crucial in critical care nursing, the situation described does not primarily involve clinical judgment but rather communication and collaboration.
D: Facilitation of learning for patients, families, and team members - While patient education is important, the main focus of the scenario is on addressing the family's concerns and facilitating communication, rather than educational aspects.
After the change-of-shift report, which patient should the progressive care nurse assess first?
- A. Patient who was extubated in the morning and has a temperature of 101.4°F (38.6°C).
- B. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16.
- C. Patient with arterial pressure monitoring who is 2 hours post percutaneous coronary intervention and needs to void.
- D. Patient who is receiving IV heparin for venous thromboembolism and has a partial thromboplastin time (PTT) of 98 seconds.
Correct Answer: D
Rationale: The correct answer is D. The patient receiving IV heparin with a PTT of 98 seconds is at risk for bleeding due to the therapeutic range of 60-80 seconds. Assessing this patient first is crucial to prevent potential bleeding complications. A high PTT indicates the blood is not clotting properly, increasing the risk of bleeding. Prompt assessment and possible adjustment of heparin infusion are needed.
A: The patient with a temperature of 101.4°F may have a fever but is not at immediate risk compared to the patient with a high PTT.
B: The patient on BiPAP with a respiratory rate of 16 is stable and does not require immediate assessment.
C: The patient post-percutaneous coronary intervention needing to void is a routine need and does not require immediate attention compared to the patient with a critical lab value.
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 four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?
- A. 36-year-old recovering from a motor vehicle crash with an alcohol withdrawal protocol.
- B. 54-year-old postoperative aortic aneurysm resection with an elevated creatinine level
- C. 86-year-old from nursing home, postoperative from coalboirnb .croemse/tecstti on
- D. 95-year-old with community-acquired pneumonia; fam ily has brought in eyeglasses and hearing aid
Correct Answer: C
Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium.
A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk.
B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C.
D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.