Nokea
Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.)
- A. Inability to communicate
- B. Invasive procedures
- C. Monitoring devices
- D. Preexisting conditions
Correct Answer: A
Rationale: The correct answer is A: Inability to communicate. Critically ill patients often experience pain and anxiety due to their inability to effectively communicate their needs and discomfort. This can lead to unaddressed pain and increased anxiety levels. Choices B, C, and D are incorrect because while invasive procedures, monitoring devices, and preexisting conditions can contribute to pain and anxiety in critically ill patients, they are not factors that directly predispose patients to these issues. It is the lack of communication that significantly hinders the ability to address and manage pain and anxiety effectively in these patients.
You may also like to solve these questions
A patient with terminal cancer reports a sudden onset of severe pain. Which intervention should the nurse implement first?
- A. Assess the patient’s pain using a standardized pain scale.
- B. Administer a PRN dose of prescribed analgesic.
- C. Notify the healthcare provider about the patient’s pain.
- D. Reposition the patient to enhance comfort.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient’s pain using a standardized pain scale. The first step is to assess the severity and nature of the pain to determine the appropriate intervention. This allows the nurse to understand the pain intensity and characteristics, which guides the choice of analgesic and dosing. Administering analgesics (B) without proper assessment can lead to inappropriate treatment. Notifying the healthcare provider (C) is important but assessing the pain should come first. Repositioning the patient (D) may provide comfort but addressing the pain directly is the priority.
The nurse is preparing to measure the thermodilution cardaiabicrb o.cuomtp/tuest t (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient?
- A. Ensure the transducer system is zero referenced at the level of the phlebostatic axis.
- B. Avoid infusing vasoactive agents in the port used to ob tain the TdCO measurement.
- C. Maintain a pressure of 300 mm Hg on the flush solutioanbi rub.scionmg/t eas tp ressure bag.
- D. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.
Correct Answer: B
Rationale: The correct answer is B: Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. This action ensures patient safety by preventing the introduction of vasoactive agents directly into the bloodstream during the measurement process. Infusing vasoactive agents can lead to inaccurate TdCO readings and potentially harm the patient.
Choice A is incorrect because zero referencing the transducer system at the level of the phlebostatic axis is important for accurate pressure monitoring but not directly related to TdCO measurement safety.
Choice C is incorrect as maintaining a pressure of 300 mm Hg on the flush solution bag is not directly related to the safety of TdCO measurement.
Choice D is incorrect as limiting the length of noncompliant pressure tubing is important for accurate pressure readings but not directly related to the safety of TdCO measurement.
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best inter pretation of these results by the nurse?
- A. The catheter is not positioned correctly and should be removed.
- B. The catheter position increases the risk of ventricular daybisrbr.hcoymth/tmesti as.
- C. The distal tip of the catheter is in the appropriate position.
- D. The physician should be called to advance the catheter into the pulmonary artery.
Correct Answer: C
Rationale: The correct answer is C: The distal tip of the catheter is in the appropriate position.
Rationale:
1. The superior vena cava is a desirable location for a central venous catheter tip placement as it is close to the heart for rapid medication delivery.
2. Catheter tip in the superior vena cava allows for proper venous return and minimizes the risk of complications.
3. The nurse does not need to remove or adjust the catheter if the tip is in the superior vena cava.
4. Advancing the catheter into the pulmonary artery (option D) would be incorrect as it can lead to serious complications.
Incorrect choices:
A: Incorrect because placement in the superior vena cava is acceptable.
B: Incorrect as placement in the superior vena cava does not increase the risk of ventricular dysrhythmias.
D: Incorrect as advancing the catheter into the pulmonary artery is unnecessary and risky.
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.
A hospice patient develops a pressure ulcer despite proper repositioning. What should the nurse include in the care plan?
- A. Implement more aggressive wound care strategies.
- B. Ensure adequate hydration and nutrition.
- C. Discuss the prognosis and expected outcomes with the family.
- D. Encourage increased physical activity to improve circulation.
Correct Answer: A
Rationale: The correct answer is A because implementing more aggressive wound care strategies is essential for managing pressure ulcers effectively. This includes proper wound cleaning, debridement, and dressing changes to promote healing. Adequate hydration and nutrition (choice B) are important but may not directly address the pressure ulcer. Discussing prognosis and expected outcomes (choice C) is important but may not directly impact wound healing. Encouraging increased physical activity (choice D) may be contraindicated due to the patient's condition.