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The critical care environment is often stressful to a criticalalbyir bil.clo pma/tteiset nt. Identify stressors that are commonly stressful for the critically ill patient. (Select all that apply.)
- A. Alarms that sound from various devices
- B. Bright, fluorescent lighting
- C. Lack of day-night cues
- D. Sounds from the mechanical ventilator
Correct Answer: A
Rationale: The correct answer is A: Alarms that sound from various devices. In the critical care environment, alarms often indicate changes in the patient's condition, causing stress. Bright fluorescent lighting (B) may be bothersome but not directly related to patient stress. Lack of day-night cues (C) may disrupt sleep patterns but is not a direct stressor. Sounds from the mechanical ventilator (D) are essential for patient care and not inherently stressful.
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The patient has just returned from having an arteriovenous fistula placed. The patient asks, “When will they be able to use this and take this other catheter out?” The nurse should reply,
- A. “It can be used immediately, so the catheter can come out anytime.”
- B. “It will take 2 to 4 weeks to heal before it can be used.”
- C. “The fistula will be usable in about 4 to 6 weeks.”
- D. “The fistula was made using graft material, so it depends on the manufacturer.”
Correct Answer: C
Rationale: The correct answer is C: “The fistula will be usable in about 4 to 6 weeks.” The rationale for this is that an arteriovenous fistula typically requires 4 to 6 weeks to mature and be ready for use. During this time, the fistula develops the necessary blood flow for efficient dialysis.
Choice A is incorrect because immediate use of the fistula is not recommended as it needs time to mature. Choice B is incorrect as it underestimates the time needed for the fistula to heal and mature. Choice D is incorrect as the usability of the fistula is not dependent on the manufacturer but rather on the patient's individual healing process.
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
- A. The patient’s heart rate is 97 beats/min.
- B. The patient’s oxygen saturation is 93%.
- C. The patient’s respiratory rate is 32 breaths/min.
- D. The patient’s spontaneous tidal volume is 450 mL.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/min indicates increased work of breathing, which could be a sign of respiratory distress. In a patient being weaned from mechanical ventilation, an elevated respiratory rate suggests that the patient may not be able to sustain adequate ventilation on their own. This warrants stopping the weaning protocol to prevent respiratory failure.
Choice A is incorrect because a heart rate of 97 beats/min is within normal range for an adult. Choice B is incorrect because an oxygen saturation of 93% is acceptable for a patient with COPD. Choice D is incorrect because a tidal volume of 450 mL is adequate for a patient weaning from mechanical ventilation.
The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best be implemented to facilitate famil y-centered care?
- A. Ensuring that the patient’s room is large enough to inc lude a sleeper sofa and storage for family members’ personal belongings.
- B. Including a diagnostic suite in close proximity to the u nit so that the patient does not have to travel far for testing.
- C. Incorporating a large waiting room on the top floor of athbierb .hcooms/pteistta l with a scenic view and amenities such as coffee and tea.
- D. Providing access to a scenic garden for meditation.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Family-centered care promotes involvement of family members in patient care.
2. A sleeper sofa in the patient's room allows family members to stay overnight, enhancing support for the patient.
3. Storage for personal belongings ensures families can have essentials close by, increasing comfort and convenience.
4. These design elements facilitate family presence, communication, and participation in care, aligning with family-centered care principles.
Summary of Incorrect Choices:
B. Having a diagnostic suite nearby is convenient but not directly related to family-centered care principles.
C. A waiting room with amenities is beneficial but does not directly involve families in patient care.
D. Access to a garden for meditation is helpful for relaxation but does not emphasize family involvement in care.
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
- A. Palpate extremities for bilateral pulses.
- B. Observe the patient’s respiratory effort.
- C. Check the patient’s level of consciousness.
- D. Examine the patient for any external bleeding.
Correct Answer: B
Rationale: Rationale: The correct action is to observe the patient's respiratory effort next. This step ensures that the patient's breathing remains stable and adequate. If respiratory effort is compromised, immediate intervention is required. Checking for bilateral pulses (A) is important but comes after ensuring respiratory status. Checking level of consciousness (C) is also crucial but not as immediate as monitoring breathing. Examining for external bleeding (D) is important but not the priority when airway and breathing are already determined to be clear.
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
- A. Glasgow Coma Scale score of 3
- B. Train-of-four yields two twitches
- C. Bispectral index of 60
- D. CAM-ICU positive
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation.
A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade.
C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level.
D: CAM-ICU assesses delirium, not neuromuscular blockade.