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The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first?
- A. A patient with a central venous pressure (RAP/CVP) oafb i6rb .mcomm/ teHstg and 40 mL of urine output in the past hour
- B. A patient with a left radial arterial line with a BP of 11 0/60 mm Hg and slightly dampened arterial waveform
- C. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula
- D. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula
Correct Answer: C
Rationale: The correct answer is C because a pulmonary artery occlusion pressure of 25 mm Hg indicates possible fluid overload or cardiac issue requiring urgent evaluation. This value is high, suggesting increased pressure in the left side of the heart. Additionally, the oxygen saturation of 89% on 3 L of oxygen indicates potential respiratory compromise. This patient needs immediate assessment and intervention to prevent worsening of their condition.
Choice A is incorrect as a central venous pressure of 6 mm Hg is within normal limits, and the urine output is adequate. Choice B is incorrect as a BP of 110/60 mm Hg is acceptable, and a slightly dampened arterial waveform is not an immediate concern. Choice D is incorrect as a pulmonary artery pressure of 25/10 mm Hg is within normal range, and an oxygen saturation of 94% on 2 L of oxygen is acceptable.
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The AACN Standards for Acute and Critical Care Nursing Practice uses what framework to guide critical care nursing practice?
- A. Evidence-based practice
- B. Healthy work environment
- C. National Patient Safety Goals
- D. Nursing process
Correct Answer: A
Rationale: The correct answer is A: Evidence-based practice. The AACN Standards for Acute and Critical Care Nursing Practice emphasize the use of evidence-based practice to guide critical care nursing. This framework ensures that nursing interventions are based on the best available evidence, leading to improved patient outcomes. Healthy work environment (B) and National Patient Safety Goals (C) are important but not specific frameworks for critical care nursing. The nursing process (D) is a systematic approach to delivering patient care but is not the primary guiding framework in critical care nursing practice.
On their first visit to a critically ill patient, family members stand in the doorway of the room, making no effort to approach the patient. What is the most appropriate nursing action?
- A. Instruct the family where the patient can be touched and what to say.
- B. Engage the family in social conversation to ease them into the milieu.
- C. Use visiting hours to explain to the family the general status of the patient.
- D. Leave the family to adjust to the situation when they are ready.
Correct Answer: A
Rationale: The correct answer is A because instructing the family on where the patient can be touched and what to say helps empower them to interact appropriately with the patient. This action promotes the family's involvement in the patient's care, encourages communication, and fosters a supportive environment. Choice B is incorrect as engaging in social conversation may not address the family's hesitance to approach the patient directly. Choice C is incorrect because waiting for visiting hours to provide information may delay necessary support for the family. Choice D is incorrect as leaving the family without guidance may perpetuate their discomfort and hinder their ability to provide emotional support to the patient.
Which patient should the nurse refer for hospice care?
- A. A 60-year-old with lymphoma whose children are unable to discuss issues related to dying.
- B. A 72-year-old with chronic severe pain due to spinal arthritis and vertebral collapse.
- C. A 28-year-old with AIDS-related dementia who needs palliative care and pain management.
- D. A 56-year-old with advanced liver failure whose family members can no longer provide care in the home.
Correct Answer: C
Rationale: The correct answer is C because the patient with AIDS-related dementia requires palliative care and pain management, which are key components of hospice care. This patient is likely in the terminal stage of their illness and would benefit from the comprehensive support provided by hospice services.
Choice A is incorrect because the patient's children's inability to discuss dying issues does not necessarily indicate a need for hospice care. Choice B is incorrect as chronic severe pain due to spinal arthritis is not a sole criterion for hospice referral. Choice D is incorrect as advanced liver failure alone does not automatically qualify a patient for hospice care.
The nurse discharging a patient diagnosed with asthma ins tructs the patient to prevent exacerbation by taking what action?
- A. Obtaining an appointment for follow-up pulmonary fuanbcirtbi.oconm s/tteusdt ies 1 week after discharge.
- B. Limiting activity until patient is able to climb two flights of stairs.
- C. Taking all asthma medications as prescribed.
- D. Taking medications on a “prn” basis according to symapbtiorbm.cosm. /test
Correct Answer: C
Rationale: The correct answer is C: Taking all asthma medications as prescribed. This is the most appropriate action to prevent exacerbation of asthma symptoms. By taking medications as prescribed, the patient can effectively manage and control their asthma, reducing the risk of exacerbation. Following the prescribed medication regimen helps to keep inflammation in check and maintain airway function.
Choice A is incorrect because while follow-up appointments are important, they do not directly prevent exacerbation. Choice B is incorrect as limiting activity may not address the underlying cause of exacerbation. Choice D is incorrect as taking medications on an "as needed" basis may not provide consistent control of asthma symptoms, leading to potential exacerbation.
A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, 'I am not ready to die.' Which action is best for the nurse to take?
- A. Remind the patient that no one feels ready for death.
- B. Sit at the bedside and ask if there is anything the patient needs.
- C. Insist that family members remain at the bedside with the patient.
- D. Tell the patient that everything possible is being done to delay death.
Correct Answer: B
Rationale: The correct answer is B because sitting at the bedside and asking if there is anything the patient needs demonstrates empathy and support. It allows the patient to express their concerns and fears, providing emotional comfort. It shows the nurse is actively listening and willing to help address any immediate needs or concerns.
Choice A is incorrect because it dismisses the patient's feelings and may come across as invalidating. Choice C is incorrect because insisting that family members remain may not be what the patient needs at that moment and could cause additional stress. Choice D is incorrect because it does not address the patient's emotional distress and may not be true in the context of terminal illness.