Nokea
Sleep often is disrupted for critically ill patients. Which nu rsing intervention is most appropriate to promote sleep and rest?
- A. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals.
- B. Encourage family members to talk with the patient wh enever they are present in the room.
- C. Keep the television on to provide “white” noise and di straction.
- D. Leave the lights on in the room so that the patient is no t frightened of his or her surroundings.
Correct Answer: A
Rationale: The correct answer is A: Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. This is the most appropriate intervention as medication timings can significantly impact sleep patterns of critically ill patients. Adjusting medication times can help synchronize rest periods, promoting uninterrupted sleep.
Choice B is incorrect as encouraging constant conversation can disrupt sleep. Choice C is incorrect as the television noise can be stimulating and hinder rest. Choice D is incorrect as leaving the lights on can disrupt the patient's circadian rhythm and negatively impact sleep quality.
You may also like to solve these questions
The nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first?
- A. Adherence to procedures by nursing staff
- B. Clarity of interdisciplinary communication
- C. Number of new employees on the unit
- D. Changes in administration procedures
Correct Answer: A
Rationale: The correct answer is A: Adherence to procedures by nursing staff. This should be evaluated first because medication errors are often caused by human factors such as staff not following proper procedures. By assessing adherence, the root cause of errors can be identified and addressed.
Choice B: Clarity of interdisciplinary communication may contribute to errors but doesn't directly address staff adherence to procedures.
Choice C: Number of new employees could be a factor, but focusing on adherence to procedures is more crucial.
Choice D: Changes in administration procedures may impact errors, but evaluating staff adherence is more immediate and directly related to errors.
A hospice patient with end-stage renal disease refuses to eat or drink and is very weak but reports no pain. Which nursing action is most appropriate?
- A. Teach the family about the use of enteral feedings to improve nutrition.
- B. Discuss the benefits of inserting a feeding tube for hydration.
- C. Provide support for the patient’s decision and ensure comfort measures.
- D. Inform the patient about the risks of refusing food and fluids.
Correct Answer: C
Rationale: The most appropriate nursing action in this scenario is choice C: Provide support for the patient’s decision and ensure comfort measures. This is because the patient is in hospice care, indicating a focus on comfort and quality of life rather than aggressive treatments. By respecting the patient’s decision and providing comfort measures, the nurse promotes dignity and autonomy. Choices A and B are not suitable as they go against the patient's wishes and may cause distress. Choice D, while important, is not the immediate priority when the patient is not in pain and has chosen to refuse food and fluids. Overall, choice C aligns with the principles of hospice care and prioritizes the patient's comfort and autonomy.
An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
- A. Urine output of 25 mL/hr.
- B. Heart rate of 110 beats/minute.
- C. Cardiac output (CO) of 5 L/min.
- D. Stroke volume (SV) of 40 mL/beat.
Correct Answer: C
Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion.
Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.
The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
- A. Continuously monitor heart rhythm.
- B. Check neurologic status every 2 hours.
- C. Place cooling blankets above and below the patient.
- D. Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Correct Answer: D
Rationale: Correct Answer: D - Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Rationale: LPNs/LVNs are trained to administer medications, including oral and nasogastric routes. Giving acetaminophen via nasogastric tube is within their scope of practice. LPNs/LVNs should have the knowledge and skills to safely administer this medication as part of the hypothermia protocol.
Summary of other choices:
A: Continuously monitor heart rhythm - This requires specialized training and skills typically within the scope of registered nurses or cardiac monitoring technicians.
B: Check neurologic status every 2 hours - Assessing neurologic status requires critical thinking and clinical judgment, which are typically responsibilities of registered nurses.
C: Place cooling blankets above and below the patient - Positioning and managing cooling devices may require specific training and should be done under the supervision of a registered nurse.
What must the patient must be able of in order to provide informed consent?
- A. Be capable of independent breathing.
- B. Have knowledge and competence to make the decision .
- C. Nod head to agree to the procedure.
- D. Both read and write in English.
Correct Answer: B
Rationale: The correct answer is B because informed consent requires the patient to have knowledge and competence to make a decision. This involves understanding the risks, benefits, and alternatives of the proposed treatment. Choice A is incorrect as it pertains to a physical ability unrelated to decision-making. Choice C is incorrect as consent must be verbal or written, not just nodding. Choice D is incorrect as consent can be obtained in various ways, not specifically through reading and writing in English.