Nokea
The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia?
- A. 21-year-old with a C4 fracture and quadriplegia
- B. 45-year-old with femur fracture and closed head injury
- C. 59-year-old postoperative elective bariatric surgery
- D. 70-year-old postoperative cardiac surgery; mild demen tia
Correct Answer: A
Rationale: The correct answer is A, the 21-year-old with a C4 fracture and quadriplegia. This patient is likely to benefit most from patient-controlled analgesia (PCA) due to the inability to self-administer traditional pain medications. With quadriplegia, the patient may have limited mobility and sensation, making it challenging to communicate pain levels effectively. PCA allows the patient to control their pain relief within preset limits, enhancing autonomy and optimizing pain management.
Summary:
- Choice B: The 45-year-old with femur fracture and closed head injury may benefit from PCA, but the severity of the head injury could affect their ability to use the device effectively.
- Choice C: The 59-year-old postoperative elective bariatric surgery patient can typically manage pain with traditional methods postoperatively.
- Choice D: The 70-year-old postoperative cardiac surgery patient with mild dementia may have the cognitive ability to use PCA but could potentially benefit more from other pain management strategies due
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A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
- A. Assess the patient’s current vital signs.
- B. Give acetaminophen (Tylenol) per agency protocol.
- C. Ask the patient to provide clean-catch urine for urinalysis.
- D. Tell the patient that it will be 1 to 2 hours before being seen by the doctor.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention.
The other choices are incorrect because:
B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment.
C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case.
D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
- A. Allowing unrestricted visiting by several family members at one time
- B. Explaining all procedures in easy-to-understand terms
- C. Providing back massage and mouth care
- D. Turning down the alarm volume on the cardiac monito r
Correct Answer: B
Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms.
A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery.
C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding.
D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.
The nurse is caring for a patient with severe neurological impairment following a massive stroke. The primary care provider has ordered tests to detearbmirbi.ncoem b/treasit n death. The nurse understands that criteria for brain death includes what crite ria? (Select all that apply.)
- A. Absence of cerebral blood flow.
- B. Absence of brainstem reflexes on neurological examin ation.
- C. Presents of Cheyne-Stokes respirations.
- D. Confirmation of a flat electroencephalogram.
Correct Answer: A
Rationale: The correct answer is A: Absence of cerebral blood flow. Brain death is determined by the irreversible cessation of all brain functions, including blood flow to the brain. When there is no cerebral blood flow, the brain is unable to function, leading to brain death. This criterion is essential in diagnosing brain death as it indicates a complete loss of brain function.
Explanation for why the other choices are incorrect:
- B: Absence of brainstem reflexes on neurological examination is a common sign of brain death, but it is not the primary criterion.
- C: Presence of Cheyne-Stokes respirations is not indicative of brain death. It is a pattern of breathing that can be seen in various conditions, not specifically brain death.
- D: Confirmation of a flat electroencephalogram is a supportive test for brain death but not the primary criterion. The absence of brain activity on an EEG can help confirm brain death but is not as definitive as the absence of cerebral blood flow.
The nurse is assessing pain levels in a critically ill patient . The nurse recognizes that which patient action as indicatin g the greatest level of pain?
- A. Brow lowering
- B. Eyelid closing
- C. Grimacing
- D. Staring
Correct Answer: C
Rationale: Correct Answer: C (Grimacing)
Rationale:
1. Grimacing is a universal nonverbal sign of pain.
2. It involves facial muscles, indicating a high level of discomfort.
3. Brow lowering and eyelid closing are subtle signs, less indicative of severe pain.
4. Staring may signify concentration, not necessarily pain.
Summary:
Grimacing is the correct choice as it directly correlates with pain intensity, unlike the other options which are less specific or relevant indicators of severe pain.
When performing an initial pulmonary artery occlusion pr essure (PAOP), what are the best nursing actions? (Select all that apply.)
- A. Inflate the balloon for no more than 8 to 10 seconds w hile noting the waveform change.
- B. Inflate the balloon with air, recording the volume nece ssary to obtain a reading.
- C. Maintain the balloon in the inflated position for 8 hours following insertion.
- D. Zero reference and level the air-fluid interface of the tr ansducer at the level of the phlebostatic axis.
Correct Answer: A
Rationale: The correct answer is A: Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. This is because inflating the balloon within this time frame allows for accurate measurement of PAOP without causing complications like pulmonary edema. Noting the waveform change helps in determining the accurate pressure reading.
Explanation of why other choices are incorrect:
B: Inflating the balloon with air and recording the volume necessary is not a recommended practice as it can lead to inaccurate readings and potential harm to the patient.
C: Maintaining the balloon inflated for 8 hours following insertion is unnecessary and could lead to complications such as vascular damage or thrombosis.
D: Zero referencing and leveling the transducer at the phlebostatic axis are important steps but not directly related to performing an initial PAOP measurement.