Nokea
The nurse is caring for a patient diagnosed with hyperactivaebi rdb.ecloimri/tuemst . The nurse focuses interventions toward which priority need?
- A. Comfort
- B. Nourishment
- C. Safety
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.
You may also like to solve these questions
The nurse is caring for a patient whose condition has deter iorated and is now not responding to standard treatment. The primary health care provider ca lls for an ethical consultation with the family to discuss potential withdrawal versus aggressivabei rtbr.ceoamtm/teestn t. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.)
- A. Burden versus benefit
- B. Family’s wishes
- C. Patient’s wishes
- D. Potential outcomes of treatment options
Correct Answer: A
Rationale: The correct answer is A: Burden versus benefit. In ethical decision-making, considering the burden of treatment on the patient versus the potential benefits is crucial. This involves weighing the risks, benefits, and potential harm of treatment options. Family's wishes (B) and patient's wishes (C) are important factors but may not always align with what is ethically best for the patient. Potential outcomes of treatment options (D) are relevant but do not directly address the ethical dilemma of balancing burden and benefit. Therefore, A is the correct choice as it directly relates to the ethical principles guiding decision-making in this scenario.
The nurse is caring for a patient with a left radial arterial lianbierb, .caonmd/t eas tp ulmonary artery catheter inserted into the right subclavian vein. Which action by th e nurse best ensures the safety of the patient being monitored with invasive hemodynamic moni toring lines?
- A. Document all waveform values.
- B. Limit the pressure tubing length.
- C. Zero reference the system daily.
- D. Ensure alarm limits are turned on.
Correct Answer: C
Rationale: The correct answer is C: Zero reference the system daily. Zero referencing ensures accuracy and calibration of pressure monitoring system by setting the baseline pressure to zero. This is crucial to prevent inaccuracies in measurements. Choice A is important but doesn't directly address the accuracy of the monitoring system. Choice B may help in preventing errors but doesn't address the accuracy of pressure measurement. Choice D is important for alerting the nurse but doesn't directly relate to the accuracy of hemodynamic monitoring.
The patient’s serum creatinine level is 0.7 mg/dL. The expected BUN level should be
- A. 1 to 2 mg/dL.
- B. 7 to 14 mg/dL.
- C. 10 to 20 mg/dL.
- D. 20 to 30 mg/dL.
Correct Answer: C
Rationale: The correct answer is C (10 to 20 mg/dL). The normal BUN-to-creatinine ratio is approximately 10:1. With a serum creatinine level of 0.7 mg/dL, the expected BUN level should be around 7 to 14 mg/dL. Therefore, choice C (10 to 20 mg/dL) falls within this expected range. Choices A, B, and D are incorrect as they do not align with the typical BUN-to-creatinine ratio and would indicate abnormal kidney function.
Which statement is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)
- A. Tooth brushing is performed every 2 hours for the greatest effect.
- B. Implementing a comprehensive oral care program is an intervention for preventing WWW .THENURSINGMASTERY.COM VAP.
- C. Oral care protocols should include oral suctioning and brushing teeth.
- D. Protocols that include chlorhexidine gluconate have beaebnirb e.cfofme/ctetsivt e in preventing VAP.
Correct Answer: B
Rationale: The correct answer is B. Implementing a comprehensive oral care program is an intervention for preventing VAP. This statement is true because proper oral care, including brushing teeth, oral suctioning, and using chlorhexidine gluconate, has been shown to reduce the risk of VAP by decreasing the colonization of pathogenic bacteria in the oral cavity. Regular oral care helps maintain oral hygiene and reduce the risk of aspiration of bacteria into the lungs, which is a common cause of VAP.
Incorrect Answer Analysis:
A: Tooth brushing every 2 hours may be excessive and could potentially cause harm to the oral mucosa, leading to increased risk of infection.
C: While oral suctioning and brushing teeth are important components of oral care, the statement is not comprehensive enough to address the full range of interventions needed to prevent VAP.
D: While chlorhexidine gluconate can be effective in preventing VAP, the statement implies that it is the only effective intervention, which is not true.
Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the criticala cbiarbr.ec osme/ttetisnt g? (Select all that apply.)
- A. Asking the family to bring in the patient’s i-Pod or other device with favorite music.
- B. Inviting the volunteer harpist to play on the unit on a re gular basis.
- C. Remodeling the unit to have two-patient rooms to facil itate nursing care.
- D. Remodeling the unit to install acoustical ceiling tiles.
Correct Answer: A
Rationale: Step 1: Bringing in the patient's i-Pod with favorite music can provide personalized, soothing sounds, reducing stress and anxiety for the patient.
Step 2: Familiar music can create a calming environment, distracting the patient from external noise.
Step 3: Listening to music may improve patient comfort and overall experience in the critical care unit.
Summary: Option A is correct as it directly addresses noise reduction by providing a personalized, calming environment for the patient. Options B, C, and D do not specifically target noise reduction but focus on other aspects of care or facility improvement.