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Which nursing intervention would need to be corrected on a care plan for a patient in order to be consistent with the principles of effective end-of-life ca re?
- A. Control of distressing symptoms such as dyspnea, naus ea, and pain through use of pharmacological and nonpharmacological interventions
- B. Limitation of visitation to reduce the emotional distresasb ierbx.cpoemr/iteesnt ced by family members
- C. Patient and family education on anticipated patient res ponses to withdrawal of therapy
- D. Provision of spiritual care resources as desired by the p atient and family
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Limiting visitation to reduce emotional distress contradicts the principles of effective end-of-life care, which emphasize holistic support for the patient and family.
2. Effective end-of-life care encourages open communication and emotional support from loved ones.
3. Limiting visitation may hinder emotional closure and support for both the patient and family.
4. Options A, C, and D align with effective end-of-life care by focusing on symptom management, education, and spiritual support for the patient and family.
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A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?
- A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
- B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
- C. Encourage the family to request that the physician evaluate the patients pain control.
- D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C
Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.
Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.
The nurse is assisting with endotracheal intubation and un derstands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.)
- A. Auscultation of air over the epigastrium
- B. Equal bilateral breath sounds upon auscultation
- C. Position above the carina verified by chest x-ray
- D. Positive detection of carbon dioxide (CO
Correct Answer: B
Rationale: The correct answer is B: Equal bilateral breath sounds upon auscultation. This indicates proper placement of the endotracheal tube in the trachea, ensuring both lungs are being ventilated equally.
Rationale:
1. Auscultation of air over the epigastrium (Choice A) is incorrect as it indicates esophageal intubation, not tracheal intubation.
2. Position above the carina verified by chest x-ray (Choice C) is incorrect as it does not confirm proper placement at the trachea.
3. Positive detection of carbon dioxide (CO2) (Choice D) is incorrect as it indicates the presence of exhaled CO2, but not necessarily proper placement in the trachea.
The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has:
- A. acute kidney injury from a prerenal condition.
- B. acute kidney injury from postrenal obstruction.
- C. intrarenal disease, probably acute tubular necrosis.
- D. a urinary tract infection.
Correct Answer: C
Rationale: The correct answer is C: intrarenal disease, probably acute tubular necrosis. The patient's symptoms of general malaise, fatigue, decreased urinary output, along with the presence of coarse, muddy brown granular casts and hematuria in the urinalysis indicate kidney damage. Acute tubular necrosis is a common cause of acute kidney injury characterized by damage to the renal tubules, leading to impaired kidney function. The presence of granular casts and hematuria suggests tubular injury and bleeding within the kidney. Choices A and B are incorrect as they refer to prerenal and postrenal causes of kidney injury, respectively, which do not align with the patient's symptoms and urinalysis findings. Choice D is incorrect as a urinary tract infection would typically present with different symptoms and urinalysis findings.
The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient’s:
- A. Lipase.
- B. Temperature.
- C. Urinary output.
- D. Body mass index.
Correct Answer: B
Rationale: The correct answer is B: Temperature. Decreased ScvO2 in severe pancreatitis can be due to systemic inflammatory response leading to increased metabolic demand and decreased tissue oxygen delivery. Monitoring temperature helps assess for presence of infection or sepsis, which can further decrease tissue oxygenation. Lipase (A) is specific for pancreatitis diagnosis, not directly related to ScvO2. Urinary output (C) is important for assessing renal function, not directly related to ScvO2. Body mass index (D) does not provide information on tissue oxygenation status in this context.
Which assessment would cue the nurse to the potential of aa bc iru bt .ce o mre /ts ep sti ratory distress syndrome (ARDS) in a patient admitted with respiratory distress?
- A. Increased oxygen saturation via pulse oximetry
- B. Increased peak inspiratory pressure on the ventilator
- C. Normal chest radiograph with enlarged cardiac structures
- D. PaO /FiO ratio > 300 2 2
Correct Answer: B
Rationale: The correct answer is B. Increased peak inspiratory pressure on the ventilator would cue the nurse to the potential of ARDS in a patient with respiratory distress. ARDS is characterized by severe respiratory failure with bilateral pulmonary infiltrates. An increase in peak inspiratory pressure on the ventilator indicates that the lungs are becoming stiffer, which is a common finding in ARDS due to increased inflammation and fluid accumulation in the alveoli. This finding alerts the nurse to the possibility of ARDS and the need for further assessment and intervention.
Summary of other choices:
A: Increased oxygen saturation via pulse oximetry is a nonspecific finding and may not specifically indicate ARDS.
C: Normal chest radiograph with enlarged cardiac structures is more indicative of heart failure rather than ARDS.
D: PaO2/FiO2 ratio > 300 is a criterion used to diagnose ARDS, but a value higher than 300 actually indicates mild ARDS, so it would not necessarily cue the nurse