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The intensive care unit (ICU) nurse educator will determine that teaching arterial pressure monitoring to staff nurses has been effective when the nurse:
- A. Balances and calibrates the monitoring equipment every 2 hours.
- B. Positions the zero-reference stopcock line level with the hemostatic axis.
- C. Ensures that the patient is supine with the head of the bed flat for all readings.
- D. Rechecks the location of the hemostatic axis when changing the patient’s position.
Correct Answer: B
Rationale: The correct answer is B because positioning the zero-reference stopcock line level with the hemostatic axis ensures accurate arterial pressure monitoring. Placing the stopcock at the hemostatic axis allows for correct measurement of blood pressure without any errors due to height differences. This positioning helps in obtaining precise and reliable readings.
A: Balancing and calibrating the monitoring equipment every 2 hours is important for equipment maintenance but does not directly impact the accuracy of arterial pressure monitoring.
C: Ensuring the patient is supine with the head of the bed flat is a standard position for arterial pressure monitoring but does not specifically address the correct positioning of the stopcock.
D: Rechecking the location of the hemostatic axis when changing the patient's position is essential for maintaining accuracy, but it does not directly relate to the initial correct positioning of the stopcock.
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Which interventions can the nurse use to facilitate communication with patients and families who are in the process of making decisions regarding end- of-life care options? (Select all that apply.)
- A. Communication of uniform messages from all healthca re team members
- B. An integrated plan of care that is developed collaborat ively by the patient, family, and healthcare team
- C. Facilitation of continuity of care through accurate shift -to-shift and transfer reports
- D. Limitation of time for families to express feelings in order to control family grief
Correct Answer: A
Rationale: The correct answer is A: Communication of uniform messages from all healthcare team members. This intervention is crucial to ensure consistency in information provided to patients and families, reducing confusion and enhancing trust. When all team members convey the same messages, it helps in clarifying options and facilitating decision-making.
Choices B and C are incorrect as they focus on care planning and continuity, which are important but not specifically related to facilitating communication in end-of-life care decisions. Choice D is incorrect as it suggests limiting time for families to express feelings, which can hinder effective communication and support during such a sensitive time.
Which statement is a likely response from someone who h as survived a stay in the critical care unit?
- A. “I don’t remember much about being in the ICU, but if I had to be treated there again, it would be okay. I’m glad I can see my grandchildren again.”
- B. “If I get that sick again, do not take me to the hospital. I would rather die than go through having a breathing tube put in again.”
- C. “My family is thrilled that I am home. I know I need some extra attention, but my children have rearranged their schedules to help me ou t.”
- D. “Since I have been transferred out of the ICU, I cannot get enough to eat. They didn’t let me eat in the ICU, so I’m making up for it no w.”
Correct Answer: A
Rationale: Rationale: Choice A is the correct answer because it reflects a positive attitude towards potential future treatments in the critical care unit and gratitude for being able to see family again. The survivor acknowledges the past experience but remains optimistic.
Summary:
- Choice B is incorrect as it shows a strong aversion to hospital care, indicating a preference for death over treatment.
- Choice C is incorrect as it focuses on the family's reaction and not the survivor's personal experience or perspective.
- Choice D is incorrect as it highlights a trivial aspect (eating) rather than reflecting on the ICU experience or future treatments.
After attending an educational program, the nurse understaanbidrbs.c othma/tte swt hich the following situations would require an ethics consultation?
- A. Conflict has occurred between the primary care provid er and family regarding treatment decisions. A family conference is held, and the family and primary care provider agree to a treatment plan that includes aggres sive treatment for 24 hours followed by re-evaluation.
- B. Family members disagree as to a patient’s course of tre atment. The patient has designated a healthcare proxy and has a written advancaebi rdb.icroemc/tteivste .
- C. A postoperative coronary artery bypass surgery patient was successfully resuscitated after sustaining a cardiopulmonary arrest i n the operating room The patient who is now not responding to treatment has a written advance directive and has a life partner at the bedside.
- D. Patient with multiple trauma and is not responding to treatment. No family members are known, and care is considered futile.
Correct Answer: D
Rationale: Step 1: The correct answer is D because the situation involves a patient with multiple trauma who is not responding to treatment and has no known family members. This indicates a complex ethical dilemma where the medical team may be unsure about the appropriate course of action.
Step 2: In this scenario, an ethics consultation is necessary to help guide decision-making regarding the care of the patient. The lack of available family members complicates decision-making, and the consideration of care as futile adds another layer of complexity.
Step 3: An ethics consultation can provide a structured framework for evaluating the situation, considering ethical principles such as beneficence, non-maleficence, autonomy, and justice. It can help the healthcare team navigate the ethical considerations and make a well-informed decision in the best interest of the patient.
Summary:
Choice A: While conflicts between the primary care provider and family may warrant discussions, the agreement on a treatment plan does not necessarily require an ethics consultation.
Choice B: Disagreement
The critical care nurse knows that in critically ill patients, renal dysfunction
- A. is a very rare problem.
- B. affects nearly two thirds of patients.
- C. has a low mortality rate once renal replacement therapy has been initiated.
- D. has little effect on morbidity, mortality, or quality of life.
Correct Answer: B
Rationale: The correct answer is B. Renal dysfunction is common in critically ill patients due to various factors like sepsis, hypotension, and nephrotoxic medications. This affects nearly two thirds of patients, making it a significant issue in critical care. Choices A, C, and D are incorrect. A is wrong because renal dysfunction is not rare in critically ill patients. C is incorrect as renal replacement therapy does not guarantee low mortality rates. D is inaccurate as renal dysfunction can have a significant impact on morbidity, mortality, and quality of life in critically ill patients.
When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.