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The nurse caring for a mechanically ventilated patient prepares to include which strategies to prevent ventilator-associated pneumonia should be into the patient’s plan of care? (Select all that apply.)
- A. Drain condensate from the ventilator tubing away from the patient.
- B. Elevate the head of the bed 30 to 45 degrees.
- C. Instill normal saline as part of the suctioning procedure.
- D. Perform regular oral care with chlorhexidine.
Correct Answer: A
Rationale: The correct answer is A: Drain condensate from the ventilator tubing away from the patient. This is crucial to prevent ventilator-associated pneumonia as stagnant condensate can harbor harmful bacteria. By draining it away from the patient, the risk of bacterial growth and subsequent aspiration is minimized. Elevating the head of the bed (choice B) helps prevent aspiration but is not specific to preventing ventilator-associated pneumonia. Instilling normal saline during suctioning (choice C) can increase the risk of infection. Performing regular oral care with chlorhexidine (choice D) is important for oral hygiene but not directly related to preventing ventilator-associated pneumonia.
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Her urine output for the past 2 hours totaled only 40 mL. She arrived from s urgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and he r blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusaiboirnb .coofm n/toesrtm al saline at 100 mL per hour. Her right atrial pressure through the subclavian cen tral line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider in creasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate fo r what part of the model?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: C
Rationale: The correct answer is C: Assessment. In the SBAR communication model, the nurse's information about the patient's history and vital signs falls under the Assessment component. This is because the nurse is providing a detailed evaluation of the patient's current condition based on objective data such as urine output, heart rate, blood pressure, and other key indicators. The nurse is analyzing the situation and forming a judgment that the patient is hypovolemic, indicating a fluid deficit. This assessment is crucial for informing further actions or interventions, such as increasing fluids or providing a fluid challenge.
Summary of other choices:
A: Situation - This choice would refer to a brief summary of the current situation without detailed analysis or interpretation.
B: Background - This choice would involve providing relevant background information about the patient, such as medical history or recent procedures, but not the current assessment of the patient's condition.
D: Recommendation - This choice would involve suggesting a course of action or treatment based on the assessment, which comes after
The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
- A. Absence of vocal sounds
- B. Fighting the ventilator
- C. Moving legs in bed
- D. Relaxed muscles in upper extremities
Correct Answer: B
Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.
What is the nurse’s priority intervention when a terminally ill patient reports severe breakthrough pain?
- A. Offer a warm compress to the painful area.
- B. Administer a prescribed PRN opioid analgesic.
- C. Reassess pain level after 2 hours.
- D. Provide distraction techniques to the patient.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed PRN opioid analgesic. This is the priority intervention because severe breakthrough pain requires immediate relief, and opioids are the most effective for managing severe pain in terminally ill patients. Warm compresses (A) may provide some comfort but do not address the underlying pain. Reassessing pain after 2 hours (C) delays necessary relief. Distraction techniques (D) are not appropriate for severe breakthrough pain as they do not directly address the pain itself. Administering the prescribed opioid analgesic promptly is crucial for providing timely and effective pain management in this situation.
The nurse is caring for a patient who is being evaluated clianbiircba.clolmy/ tfeostr brain death by a primary care provider. Which assessment findings by the nurse sup port brain death?
- A. Absence of a corneal reflex
- B. Unequal, reactive pupils
- C. Withdrawal from painful stimuli
- D. Core temperature of 100.8° F
Correct Answer: A
Rationale: The correct answer is A, absence of a corneal reflex, because in brain death, all brainstem reflexes, including the corneal reflex, are absent. This indicates complete loss of brain function. Choice B, unequal reactive pupils, is incorrect as it suggests some level of brainstem function. Choice C, withdrawal from painful stimuli, is also incorrect as it is a spinal reflex and can occur even in the absence of brain function. Choice D, core temperature of 100.8° F, is irrelevant to assessing brain death.
In which situation would a healthcare surrogate or proxy a ssume the end-of-life decision-making role for a patient?
- A. When a dying patient requires extensive heavy sedatioanb,i rbs.ucocmh/ taesst benzodiazepines and narcotics, to control distressing symptoms
- B. When a dying patient who is competent requests to wi thdraw treatment against the wishes of the family
- C. When a dying patient who is competent requests to con tinue treatment against the recommendations of the healthcare team
- D. When a dying patient who is competent is receiving pr n treatment for pain and anxiety
Correct Answer: A
Rationale: The correct answer is A because in this situation, the patient is no longer able to make decisions for themselves due to being heavily sedated. The healthcare surrogate or proxy steps in to make decisions on behalf of the patient to ensure their comfort and well-being.
Choice B is incorrect because the patient is competent and able to make their own decisions, so there is no need for a surrogate to take over decision-making.
Choice C is incorrect because the patient is competent and has the right to make decisions about their own treatment, even if they go against medical recommendations.
Choice D is incorrect because the patient is competent and receiving appropriate treatment for their pain and anxiety, so there is no need for a surrogate to intervene in this scenario.