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The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications?
- A. Give around-the-clock routine administration of analgesics.
- B. Provide PRN doses of medication whenever the patient requests.
- C. Offer enough pain medication to keep the patient sedated.
- D. Suggest analgesic doses that provide pain control without decreasing respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Give around-the-clock routine administration of analgesics. This is the best approach for managing continuous and severe pain in a terminally ill patient. By providing scheduled doses of opioid pain medications, the nurse ensures a consistent level of pain relief, preventing peaks and troughs in pain control. This approach also helps in preventing the patient from experiencing unnecessary suffering.
Choice B (PRN doses) may lead to inadequate pain control as the patient may wait too long before requesting medication. Choice C (keeping the patient sedated) is not appropriate as the goal is pain management, not sedation. Choice D (balancing pain control and respiratory rate) is important, but the priority should be on effectively managing the pain first.
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The nurse is caring for a patient in the critical care unit whaobi,r ba.cfotemr/ tebset ing declared brain dead, is being managed by the OPO transplant coordinator. Thir ty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, hear t rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO ) is 99% and 2 core temperature 93.8° F. Which primary care provider ord er should the nurse implement first?
- A. Apply forced air warming device to keep temperature > 96.8° F
- B. Obtain basic metabolic panel every 4 hours until surgery
- C. Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg
- D. Draw arterial blood gas every 4 hours until surgery
Correct Answer: C
Rationale: The correct answer is C: Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg. The nurse should implement this order first because the patient's low blood pressure (75/50 mm Hg) indicates hypotension, which can lead to inadequate perfusion to vital organs. Phenylephrine is a vasoconstrictor that can help increase the patient's blood pressure and improve perfusion. It is crucial to address hypotension promptly to prevent further complications.
Choice A is incorrect because maintaining the patient's temperature above 96.8°F is not the most urgent concern in this scenario. Choice B is incorrect as obtaining a basic metabolic panel every 4 hours is not the immediate priority when the patient is experiencing hypotension. Choice D is incorrect as drawing arterial blood gas every 4 hours is not the most urgent intervention needed to address the patient's low blood pressure.
A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply.
- A. His daughters conversation
- B. His daughters effleurage
- C. The beeping of the heart monitor
- D. The dim lighting of the room
Correct Answer: C
Rationale: The correct answer is C: The beeping of the heart monitor is a likely stressor for the patient recovering from open-heart surgery in the ICU. The constant beeping can cause anxiety and uncertainty about their health status. The daughter's conversation and effleurage are likely comforting and supportive for the patient, reducing stress. The dim lighting may create a calming environment, and the distant cries of a patient in pain may evoke empathy but may not directly stress the recovering patient. Therefore, the beeping of the heart monitor stands out as a stressor among the choices provided.
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?
- A. One chronic and one acute illness.
- B. Two acute illnesses.
- C. One acute and one infectious illness.
- D. Two chronic illnesses.
Correct Answer: A
Rationale: The correct answer is A: One chronic and one acute illness. This is because Type 2 diabetes mellitus is a chronic condition, while influenza is an acute illness. The nurse should develop goals addressing the management and control of the chronic condition (diabetes) as well as the treatment and recovery from the acute illness (influenza). This approach ensures comprehensive care that considers both the long-term management of the chronic illness and the immediate needs related to the acute illness.
Choices B, C, and D are incorrect because they do not address the combination of chronic and acute illnesses presented in the scenario. Choice B focuses solely on two acute illnesses, which overlooks the ongoing management required for the chronic condition. Choice C combines an acute and an infectious illness, but fails to account for the chronic illness component. Choice D involves two chronic illnesses, neglecting the immediate care needed for the acute illness.
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
- A. Fit the client with a respirator mask.
- B. Assign the client to a negative air-flow room.
- C. Don a clean gown for client care.
- D. Place an isolation cart in the hallway.
Correct Answer: B
Rationale: The correct answer is B: Assign the client to a negative air-flow room. This is crucial to prevent the spread of TB to other patients and healthcare workers. Negative air-flow rooms help contain airborne pathogens. Option A is not sufficient as it only protects the client, not others. Option C is important for infection control but not the priority in this situation. Option D is not as effective as placing the client in a negative air-flow room. Overall, option B is the best choice to ensure the safety of everyone in the unit.
What term is used to describe a specific request made by a competent person that directs medical care related to life-prolonging procedures if the pa tient loses capacity to make decisions?
- A. Do not resuscitate order
- B. Healthcare proxy
- C. Informed consent
- D. Living will
Correct Answer: D
Rationale: The correct answer is D, Living will. A living will is a legal document that outlines a person's preferences for medical treatment if they become unable to communicate their wishes. It specifically addresses life-prolonging procedures. Option A, Do not resuscitate order, is a specific directive to not perform CPR in case of cardiac arrest, not a comprehensive medical care directive. Option B, Healthcare proxy, is a person designated to make medical decisions on behalf of a patient who is unable to do so, not the specific directive itself. Option C, Informed consent, refers to the process of obtaining permission from a patient before conducting a healthcare intervention, not a directive for life-prolonging procedures.