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When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.)
- A. Unmarried life partners of same sex
- B. Unmarried life partners of opposite sex
- C. Roommates
- D. Close friends
Correct Answer: A
Rationale: The correct answer is A: Unmarried life partners of same sex. When providing palliative care, it's crucial to recognize and respect diverse family structures. Unmarried life partners of the same sex may form a significant familial bond, requiring support and involvement in care decisions. This choice aligns with the principles of inclusivity and non-discrimination in palliative care.
Incorrect choices:
B: Unmarried life partners of the opposite sex - This choice is incorrect as it limits the definition of family to only opposite-sex partners, excluding same-sex couples.
C: Roommates - While roommates may provide support, they do not necessarily have the same level of emotional and decision-making involvement as family members or life partners.
D: Close friends - While close friends can be important sources of support, they do not necessarily have the same legal or emotional ties as a life partner.
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Which intervention about visitation in the critical care unit is true?
- A. The majority of critical care nurses implement restricte d visiting hours to allow the patient to rest.
- B. Children should never be permitted to visit a critically ill family member.
- C. Visitation that is individualized to the needs of patients and family members is ideal.
- D. Visiting hours should always be unrestricted.
Correct Answer: C
Rationale: The correct answer is C because individualized visitation meets the unique needs of patients and family members, promoting holistic care and emotional support. Choice A is incorrect as strictly restricted visiting hours may hinder family involvement in care. Choice B is incorrect as children can provide comfort and support. Choice D is incorrect as unrestricted visiting may disrupt patient rest and care routines.
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.
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
- A. Predict the likelihood of the outcome.
- B. Consider alternatives.
- C. Choose the most successful approach.
- D. Identify the problem.
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.
A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.
B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.
C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should:
- A. Obtain a complete set of vital signs.
- B. Obtain a Glasgow Coma Scale score.
- C. Ask about chronic medical conditions.
- D. Attach a cardiac electrocardiogram monitor.
Correct Answer: B
Rationale: The correct answer is B: Obtain a Glasgow Coma Scale score. During the primary survey, assessing the patient's level of consciousness is crucial as it helps determine the severity of the injury and guides further management. The Glasgow Coma Scale is a standardized tool used to assess the level of consciousness based on eye opening, verbal response, and motor response. It provides valuable information about the patient's neurological status.
A: Obtaining a complete set of vital signs is important but assessing the level of consciousness takes priority in this scenario.
C: Asking about chronic medical conditions is important but not as critical as assessing the patient's level of consciousness during the primary survey.
D: Attaching a cardiac electrocardiogram monitor is not necessary during the primary survey unless there are specific indications of cardiac issues, which are not evident in this case.
In summary, obtaining a Glasgow Coma Scale score is essential for assessing the patient's level of consciousness and determining the severity of the injury during the primary survey.
A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
- A. Blood transfusion
- B. Furosemide
- C. Dobutamine infusion
- D. Dopamine hydrochloride infusion
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion.
Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.