Nokea
Following surgery for an abdominal aortic aneurysm, the patient’s central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?
- A. Administer IV diuretic medications.
- B. Increase the IV fluid infusion per protocol.
- C. Document the CVP and continue to monitor.
- D. Elevate the head of the patient's bed to 45 degrees.
Correct Answer: B
Rationale: The correct answer is B: Increase the IV fluid infusion per protocol. Low CVP post-abdominal aortic aneurysm surgery could indicate hypovolemia, which requires fluid resuscitation. Increasing IV fluid infusion helps restore intravascular volume, improve tissue perfusion, and prevent hypotension. Administering diuretics (A) would worsen hypovolemia. Documenting (C) is important but not the priority when the patient needs immediate intervention. Elevating the head of the bed (D) may help with venous return but is not the priority over addressing hypovolemia.
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A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply.
- A. His daughters conversation
- B. His daughters effleurage
- C. The beeping of the heart monitor
- D. The dim lighting of the room
Correct Answer: C
Rationale: The correct answer is C: The beeping of the heart monitor is a likely stressor for the patient recovering from open-heart surgery in the ICU. The constant beeping can cause anxiety and uncertainty about their health status. The daughter's conversation and effleurage are likely comforting and supportive for the patient, reducing stress. The dim lighting may create a calming environment, and the distant cries of a patient in pain may evoke empathy but may not directly stress the recovering patient. Therefore, the beeping of the heart monitor stands out as a stressor among the choices provided.
Which interventions may be included during “terminal we aning”? (Select all that apply.)
- A. Complete extubation following ventilator withdrawal
- B. Discontinuation of artificial ventilation but maintenanc e of the artificial airway
- C. Discontinuation of anxiolytic and pain medications
- D. Titration of ventilator support based upon blood gas de terminations
Correct Answer: B
Rationale: The correct answer is B because during terminal weaning, the artificial ventilation is discontinued while maintaining the artificial airway to ensure comfort and support. This allows the patient to breathe on their own with support as needed.
Explanation:
1. Option A: Complete extubation following ventilator withdrawal may not be suitable during terminal weaning as it involves removing the breathing tube entirely.
2. Option C: Discontinuation of anxiolytic and pain medications may not always be appropriate during terminal weaning as it depends on the patient's comfort needs.
3. Option D: Titration of ventilator support based on blood gas determinations is not typically done during terminal weaning as the focus is on gradual withdrawal of ventilation support while maintaining comfort.
Comparing the patient’s current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next care provider when the patient is transferred within an organization or to another setting a re strategies toward best achieving what patient related goal?
- A. Improving accuracy of patient identification.
- B. Preventing errors related to look-alike and sound-alike medications.
- C. Reconciling medications across the continuum of care.
- D. Reducing harms associated with administration of anti coagulants.
Correct Answer: C
Rationale: Step 1: Reconciling medications is essential for patient safety as it involves comparing current and ordered medications to ensure accuracy.
Step 2: This process helps prevent medication errors, adverse drug reactions, and duplications across different care settings.
Step 3: Communicating a complete list of medications to the next care provider ensures continuity of care and reduces the risk of medication discrepancies.
Step 4: By reconciling medications across the continuum of care, healthcare providers can better coordinate patient care and optimize treatment outcomes.
In summary, choice C is correct as it focuses on medication reconciliation to improve patient safety and care coordination. Choices A, B, and D are incorrect as they do not directly address the comprehensive process of reconciling medications across care settings.
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces th e risk of catheter-related bloodstream infection (CRBSI)?
- A. Review daily the necessity of the central venous cathet er.
- B. Cleanse the insertion site daily with isopropyl alcohol.
- C. Change the pressurized tubing system and flush bag daily.
- D. Maintain a pressure of 300 mm Hg on the flush bag.
Correct Answer: A
Rationale: The correct answer is A: Review daily the necessity of the central venous catheter. This action reduces the risk of CRBSI by promoting early removal of unnecessary catheters, which is a key strategy in preventing infections. Unnecessary catheters increase the risk of infection due to prolonged exposure to the patient's skin flora and possible contamination during insertion. Reviewing daily ensures the catheter is only kept when necessary, minimizing the duration of catheter use and reducing the chances of infection.
Summary of other choices:
B: Cleansing the insertion site daily with isopropyl alcohol is important for maintaining skin integrity but does not directly reduce the risk of CRBSI.
C: Changing the pressurized tubing system and flush bag daily is important for maintaining catheter patency but does not directly reduce the risk of CRBSI.
D: Maintaining a pressure of 300 mm Hg on the flush bag is important for proper catheter function but does not directly reduce the risk of CR
The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications?
- A. Give around-the-clock routine administration of analgesics.
- B. Provide PRN doses of medication whenever the patient requests.
- C. Offer enough pain medication to keep the patient sedated.
- D. Suggest analgesic doses that provide pain control without decreasing respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Give around-the-clock routine administration of analgesics. This is the best approach for managing continuous and severe pain in a terminally ill patient. By providing scheduled doses of opioid pain medications, the nurse ensures a consistent level of pain relief, preventing peaks and troughs in pain control. This approach also helps in preventing the patient from experiencing unnecessary suffering.
Choice B (PRN doses) may lead to inadequate pain control as the patient may wait too long before requesting medication. Choice C (keeping the patient sedated) is not appropriate as the goal is pain management, not sedation. Choice D (balancing pain control and respiratory rate) is important, but the priority should be on effectively managing the pain first.