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To prevent any unwanted resuscitation after life-sustaininga btirrbe.acotmm/teenstt s have been withdrawn, the nurse should ensure that what intervention has been im plemented?
- A. Do-not-resuscitate (DNR) orders are written before dis continuation of the treatments.
- B. The family is not allowed to visit until the death occur s.
- C. DNR orders are written as soon as possible after the di scontinuation of the treatments.
- D. The change-of-shift report includes the information thaatb irtbh.ceo pma/tetiset nt is not to be resuscitated.
Correct Answer: A
Rationale: The correct answer is A because writing DNR orders before discontinuation of life-sustaining treatments ensures clear communication and legal documentation of the patient's wishes. Choice B is incorrect as family support is essential in end-of-life care. Choice C is incorrect as DNR orders should be established before withdrawing treatment. Choice D is incorrect as the DNR order should be in place before shift change for immediate implementation if needed.
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The nurse is caring for a patient receiving benzodiazepine intermittently. What is the best way to administer such drugs?
- A. Medicate around the clock, rather than as needed, to en sure constant sedation.
- B. Administer the medications through the feeding tube to prevent complications.
- C. Give the highest allowable dose for the greatest effect.
- D. Titrate to a predefined endpoint using a standard sedat ion scale.
Correct Answer: D
Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects.
A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects.
B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications.
C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?
- A. Antiseptic oral care
- B. Bed rest with head of bed elevated
- C. Coughing and deep breathing
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots.
A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism.
B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility.
C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority?
- A. Decrease the suction pressure to 80 mm Hg.
- B. Document the dysrhythmia in the patient’s chart.
- C. Stop and ventilate the patient with 100% oxygen.
- D. Give antidysrhythmic medications per protocol.
Correct Answer: C
Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.
Intrapulmonary shunting refers to what outcome?
- A. Alveoli that are not perfused.
- B. Blood that is shunted from the left side of the heart to t he right and causes heart failure.
- C. Blood that is shunted from the right side of the heart to the left without oxygenation.
- D. Shunting of blood supply to only one lung.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Intrapulmonary shunting refers to blood bypassing the normal oxygenation process in the lungs.
2. Choice C describes blood being shunted from the right side of the heart (deoxygenated blood) to the left side without oxygenation, leading to systemic circulation without oxygenation.
3. Choices A, B, and D do not accurately describe intrapulmonary shunting as they focus on other concepts like alveolar perfusion, heart failure, and unilateral lung blood supply, respectively.
A family member tells the nurse, 'I don’t know how I’m going to manage without my mother. She took care of everything for us.' Which response by the nurse is most appropriate?
- A. You will learn how to manage things gradually, and I can provide some resources to help you.
- B. It will be difficult at first, but time will help you adjust to her loss.
- C. Perhaps another family member can take over the responsibilities your mother managed.
- D. It sounds like you will need to seek professional counseling to cope with this loss.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the family member's feelings while offering support and resources for managing the situation gradually. By providing resources, the nurse empowers the family member to learn how to handle things independently over time. This approach promotes self-reliance and resilience.
Choice B focuses on time rather than active coping strategies, which may not address the family member's immediate needs. Choice C suggests shifting responsibilities to another family member without considering the emotional impact. Choice D jumps to the conclusion of needing professional counseling without exploring other potential solutions or support systems.