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The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.)
- A. Adjust lighting to promote normal sleep-wake cycles.
- B. Provide clocks, calendars, and personal photos in the p atient’s room.
- C. Talk to the patient about other patients you are caring for on the unit.
- D. Tell the patient the day and time when you are providi ng routine nursing interventions.
Correct Answer: A
Rationale: Correct Answer: A. Adjust lighting to promote normal sleep-wake cycles.
Rationale:
1. Adjusting lighting can help regulate the patient's circadian rhythm, promoting better sleep and reducing stress.
2. Normal sleep-wake cycles are crucial for overall well-being and healing in a critical care setting.
3. Proper lighting can also create a more calming environment for the patient.
Summary of Incorrect Choices:
B. Providing clocks, calendars, and personal photos can be overwhelming for a stressed patient.
C. Talking about other patients may increase anxiety and breach patient confidentiality.
D. Telling the day and time of routine interventions may disrupt the patient's sense of time and add to stress.
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The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
- A. Check quickly for possible causes of the alarm that can be fixed.
- B. After troubleshooting, connect back to mechanical venti lator and reassess patient.
- C. Go to patient’s bedside.
- D. Manually ventilate the patient while getting respiratory therapist.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.
The nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first?
- A. Adherence to procedures by nursing staff
- B. Clarity of interdisciplinary communication
- C. Number of new employees on the unit
- D. Changes in administration procedures
Correct Answer: A
Rationale: The correct answer is A: Adherence to procedures by nursing staff. This should be evaluated first because medication errors are often caused by human factors such as staff not following proper procedures. By assessing adherence, the root cause of errors can be identified and addressed.
Choice B: Clarity of interdisciplinary communication may contribute to errors but doesn't directly address staff adherence to procedures.
Choice C: Number of new employees could be a factor, but focusing on adherence to procedures is more crucial.
Choice D: Changes in administration procedures may impact errors, but evaluating staff adherence is more immediate and directly related to errors.
The nurse calculates the PaO /FiO ratio for the following values: PaO is 78 mm Hg; FiO is 2 2 2 2 6 (60%). What is the outcome and the relationship to the ARDS diagnosing criteria?
- A. 46.8; meets criteria for ARDS
- B. 130; meets criteria for ARDS
- C. 468; normal lung function
- D. Not enough data to compute the ratio
Correct Answer: A
Rationale: The correct answer is A: 46.8; meets criteria for ARDS. The PaO /FiO ratio is calculated by dividing the arterial oxygen partial pressure (PaO) by the fraction of inspired oxygen (FiO). In this case, PaO is 78 mm Hg and FiO is 0.6 (60%). Therefore, the calculation would be 78/0.6 = 130. This value is less than 300, which is indicative of ARDS according to the Berlin criteria. Choices B and C are incorrect as they do not align with the criteria for ARDS. Choice D is incorrect because the data provided is sufficient to compute the ratio.
A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
- A. Administer fentanyl (Duragesic) 25 mg IV bolus.
- B. Administer midazolam 2 mg IV now.
- C. Increase the rate of the morphine infusion by 50%.
- D. Request an order for a paralytic agent.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Midazolam is a benzodiazepine used for sedation and anxiolysis.
2. It acts quickly and has a short duration of action, suitable for acute agitation.
3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility.
4. Lorazepam is specifically ordered for this patient, indicating its appropriateness.
5. Administering midazolam addresses the patient's agitation efficiently and safely.
Summary of why other choices are incorrect:
A: Fentanyl is an opioid analgesic, not ideal for managing agitation.
C: Increasing morphine infusion can exacerbate sedation or respiratory depression.
D: Paralytic agents are used for neuromuscular blockade, not agitation control.
The nurse is caring for a mechanically ventilated patient b eing monitored with a left radial arterial line. During the inspiratory phase of ventilation, th e nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse?
- A. The mechanical ventilator is malfunctioning.
- B. The patient may require fluid resuscitation.
- C. The arterial line may need to be replaced.
- D. The left limb may have reduced perfusion.
Correct Answer: B
Rationale: The correct answer is B: The patient may require fluid resuscitation. A decrease in arterial blood pressure during the inspiratory phase of ventilation suggests decreased preload, indicating possible hypovolemia. This can be addressed by administering fluid resuscitation to improve cardiac output and blood pressure.
Incorrect Choices:
A: The mechanical ventilator is malfunctioning - There is no evidence to suggest a ventilator malfunction based on the arterial pressure change.
C: The arterial line may need to be replaced - The arterial line itself is unlikely to cause the observed pressure change.
D: The left limb may have reduced perfusion - This is less likely as the pressure change is likely systemic due to decreased preload.