Nokea
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
- A. Remove the patient’s rings.
- B. Apply ice packs to both hands.
- C. Apply calamine lotion to any itching areas.
- D. Give diphenhydramine (Benadryl) 50 mg PO.
Correct Answer: A
Rationale: The correct answer is A: Remove the patient's rings first. This is crucial to prevent constriction and swelling due to potential allergic reactions or inflammation from bee stings. Removing rings allows for proper circulation and prevents complications like compartment syndrome. Ice packs (B) can be applied after removing the rings to reduce swelling. Calamine lotion (C) can provide relief for itching but is not as urgent as ring removal. Diphenhydramine (D) can be given later for systemic allergic reactions but should not take precedence over removing the rings.
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What is the nurse’s priority intervention when a terminally ill patient reports severe breakthrough pain?
- A. Offer a warm compress to the painful area.
- B. Administer a prescribed PRN opioid analgesic.
- C. Reassess pain level after 2 hours.
- D. Provide distraction techniques to the patient.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed PRN opioid analgesic. This is the priority intervention because severe breakthrough pain requires immediate relief, and opioids are the most effective for managing severe pain in terminally ill patients. Warm compresses (A) may provide some comfort but do not address the underlying pain. Reassessing pain after 2 hours (C) delays necessary relief. Distraction techniques (D) are not appropriate for severe breakthrough pain as they do not directly address the pain itself. Administering the prescribed opioid analgesic promptly is crucial for providing timely and effective pain management in this situation.
What is the treatment for an acute exacerbation of asthma?
- A. Corticosteroids and theophylline by mouth
- B. Inhaled bronchodilators and intravenous corticosteroids
- C. Prone positioning or continuous lateral rotation
- D. Sedation and inhaled bronchodilators
Correct Answer: B
Rationale: The correct answer is B: Inhaled bronchodilators and intravenous corticosteroids. Bronchodilators help to quickly open up the airways during an asthma exacerbation, providing immediate relief. Intravenous corticosteroids help reduce airway inflammation and prevent further worsening of symptoms. Corticosteroids by mouth (Choice A) are not as effective as intravenous administration during an acute exacerbation. Prone positioning or continuous lateral rotation (Choice C) is not a recommended treatment for asthma exacerbation. Sedation and inhaled bronchodilators (Choice D) are not appropriate as sedation can depress respiratory function and worsen the condition.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
- A. The patient’s oxygen saturation is 93%.
- B. The patient was last suctioned 6 hours ago.
- C. The patient’s respiratory rate is 32 breaths/minute.
- D. The patient has occasional audible expiratory wheezes.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/minute indicates increased work of breathing, which could be due to secretions that need to be suctioned. High respiratory rate may suggest inadequate oxygenation and ventilation. Oxygen saturation of 93% (choice A) is within an acceptable range and does not necessarily indicate the need for suctioning. Time since last suctioning (choice B) should be considered but is not as immediate an indication as an increased respiratory rate. Occasional audible expiratory wheezes (choice D) may be indicative of other respiratory issues but do not directly indicate the need for suctioning.
What nursing strategies help families cope with the stress of critical illness? (Select all that apply.)
- A. Asking the family to leave during the morning bath to promote the patient’s privacy.
- B. Encouraging family members to make notes of questio ns they have for the physician during family rounds.
- C. When possible, providing continuity of nursing care.
- D. Providing a daily update of the patient’s condition to the family spokesperson.
Correct Answer: B
Rationale: The correct answer is B: Encouraging family members to make notes of questions they have for the physician during family rounds. This strategy helps families cope with the stress of critical illness by empowering them to stay informed and actively participate in the patient's care. By encouraging them to make notes, it promotes effective communication with the healthcare team and ensures that their concerns and questions are addressed promptly.
Other choices are incorrect:
A: Asking the family to leave during the morning bath to promote the patient’s privacy is not a helpful strategy for coping with stress as it may lead to feelings of isolation and lack of involvement in the patient's care.
C: Providing continuity of nursing care is important but may not directly address the family's coping mechanisms during a critical illness.
D: Providing a daily update of the patient’s condition to the family spokesperson is valuable but may not fully address the family's need for active participation and communication with the healthcare team.
A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty?
- A. It will result in a salary increase.
- B. It is required to work in critical care.
- C. It demonstrates the nurses personal expertise.
- D. It is mandated by employers.
Correct Answer: C
Rationale: The correct answer is C because obtaining certification in critical care nursing demonstrates the nurse's personal expertise in the specialty. Certification confirms the nurse's advanced knowledge and skills, enhancing professional credibility and potential for career advancement. This choice focuses on the individual nurse's competency and dedication to the specialty.
Incorrect choices:
A: Salary increase is not the primary benefit of certification, although it may be a potential outcome.
B: Certification is often preferred but not always required to work in critical care.
D: Employers may encourage certification, but it is not always mandated.