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The nurse caring for a critically ill patient implements several components of care. What component is an example of the use of evidence-based practice?
- A. Use of a protocol for admission of a patient to the unit
- B. Application of an insulin sliding scale method from research
- C. Checking the patients armband before giving a medication
- D. Limiting visits to immediate family only for 2 hours a day
Correct Answer: B
Rationale: The correct answer is B because applying an insulin sliding scale method based on research is an example of evidence-based practice. This method is derived from scientific evidence and research studies, ensuring the best outcomes for the patient. The other choices lack the same level of evidence-based rationale: A is based on a protocol, which may not be evidence-based; C is a standard safety practice, not necessarily evidence-based; D is a decision based on hospital policy or practicality, not specifically evidence-based.
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When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment?
- A. Central venous pressure (CVP)
- B. Systemic vascular resistance (SVR)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The correct answer is C: Pulmonary vascular resistance (PVR). PVR is the most appropriate parameter to monitor in a patient with pulmonary hypertension as it directly reflects the resistance in the pulmonary circulation. A decrease in PVR indicates a reduction in the constriction of blood vessels in the lungs, suggesting improvement in pulmonary hypertension. Monitoring CVP (A) is more relevant in assessing fluid status, SVR (B) is more indicative of systemic vascular tone, and PAWP (D) is useful in assessing left-sided heart function, but they are not as specific to evaluating the effectiveness of treatment for pulmonary hypertension.
A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
- A. Heart rate.
- B. Breath sounds.
- C. Body temperature.
- D. Level of consciousness.
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia?
- A. 21-year-old with a C4 fracture and quadriplegia
- B. 45-year-old with femur fracture and closed head injury
- C. 59-year-old postoperative elective bariatric surgery
- D. 70-year-old postoperative cardiac surgery; mild demen tia
Correct Answer: A
Rationale: The correct answer is A, the 21-year-old with a C4 fracture and quadriplegia. This patient is likely to benefit most from patient-controlled analgesia (PCA) due to the inability to self-administer traditional pain medications. With quadriplegia, the patient may have limited mobility and sensation, making it challenging to communicate pain levels effectively. PCA allows the patient to control their pain relief within preset limits, enhancing autonomy and optimizing pain management.
Summary:
- Choice B: The 45-year-old with femur fracture and closed head injury may benefit from PCA, but the severity of the head injury could affect their ability to use the device effectively.
- Choice C: The 59-year-old postoperative elective bariatric surgery patient can typically manage pain with traditional methods postoperatively.
- Choice D: The 70-year-old postoperative cardiac surgery patient with mild dementia may have the cognitive ability to use PCA but could potentially benefit more from other pain management strategies due
All of the patient’s children are distressed by the possibility of removing life-support treatments. The child who is most upset tells the nurse, “T his is the same as killing! I thought you were supposed to help!” What response would the nur se provide to the family?
- A. “This is a process of allowing death to occur naturally after the injuries that were sustained in a serious accident.”
- B. “The hospital would never allow us to do that kind of thing.”
- C. “Let’s talk about this calmly, and I will explain why asasbiirsbt.ecodm s/tuesict ide is appropriate in this case.”
- D. “Your parent lived a long and productive life.”
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Acknowledges the child's distress and concerns.
2. Explains the concept of allowing natural death after serious injuries.
3. Helps the family understand the ethical and medical reasoning behind removing life support.
4. Shows empathy and provides education to address misconceptions.
Summary of other choices:
B: Incorrect - Avoids addressing the family's concerns and provides a vague response.
C: Incorrect - Contains a typo and does not directly address the child's distress or misunderstanding.
D: Incorrect - Irrelevant response that does not address the ethical dilemma at hand.
The nurse is preparing to provide postmortem care for a patient who has just died. Which action should the nurse take first?
- A. Close the patient’s eyes and place a pillow under the head.
- B. Wash the patient’s body and apply a clean gown.
- C. Remove all medical equipment and tubes.
- D. Confirm that a death certificate has been signed.
Correct Answer: A
Rationale: Rationale:
A: Closing the patient's eyes and placing a pillow under the head is the first step in postmortem care to maintain dignity and prevent airway occlusion.
B: Washing the body and changing clothes can be done later and is not the priority.
C: Removing medical equipment can wait until after ensuring the patient's comfort.
D: Confirming the death certificate is important but not the immediate first step in postmortem care.