Nokea
The nurse cites evidence-based practice as a rationale for a patient care decision. What isthe best description of evidence-based practice?
- A. Decisions based on expert legal testimony
- B. Use of best available research data
- C. Evolution of nursing practice over time
- D. Individual optimization of patient outcomes
Correct Answer: B
Rationale: The correct answer is B: Use of best available research data. Evidence-based practice involves integrating the best available research evidence with clinical expertise and patient values to make informed decisions about patient care. It emphasizes using scientifically proven data to guide practice and improve patient outcomes. Expert legal testimony (A) is not necessarily evidence-based. Evolution of nursing practice over time (C) does not specifically focus on research data. Individual optimization of patient outcomes (D) is a goal of evidence-based practice, but it does not fully encompass the concept.
You may also like to solve these questions
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. Has the client experienced constipation recently?
- B. Did the client miss any doses of the medication?
- C. How long has the client been taking the medication?
- D. Does the client use any tobacco products?
Correct Answer: C
Rationale: The correct answer is C. Assessing how long the client has been taking clonidine is crucial as drowsiness is a common side effect that typically improves over time as the body adjusts to the medication. This information helps determine if the drowsiness is a temporary side effect or a more concerning issue.
Choice A (constipation) is not directly related to drowsiness as a side effect of clonidine. Choice B (missed doses) may contribute to drowsiness but is not the primary assessment priority. Choice D (tobacco use) is not directly related to clonidine-induced drowsiness.
A patient with end-stage heart failure is experiencing consaibdirebr.caobmle/te dsty spnea. What is the appropriate pharmacological management of this symptom ?
- A. Administration of 6 mg of midazolam and initiation of a continuous midazolam infusion.
- B. Administration of morphine, 5 mg IV bolus, and initia tion of a continuous morphine infusion.
- C. Hourly increases of the midazolam (Versed) infusion b y 100% dose increments.
- D. Hourly increases of the morphine infusion by 100% dose increments.
Correct Answer: B
Rationale: The correct answer is B: Administration of morphine, 5 mg IV bolus, and initiation of a continuous morphine infusion. Morphine is the preferred pharmacological management for severe dyspnea in end-stage heart failure due to its potent analgesic and anxiolytic properties.
Step-by-step rationale:
1. Morphine is a potent opioid that helps relieve dyspnea by reducing anxiety, decreasing respiratory drive, and improving overall comfort.
2. The initial IV bolus of 5 mg provides rapid relief of dyspnea.
3. Initiating a continuous morphine infusion ensures sustained relief of dyspnea.
4. Midazolam (choice A) is a benzodiazepine used for sedation and anxiety, but it is not the first-line treatment for dyspnea in this scenario.
5. Increasing the midazolam (choice C) or morphine (choice D) infusions by 100% dose increments hourly is not appropriate as
Which statement reflects adherence to current recommendations concerning open visitation policies?
- A. Allowing animals on the unit; however, these can only be “therapy” animals through the hospital’s pet therapy program.
- B. Allowing family visitation throughout the day except a t change of shift and during rounds.
- C. Determining, in collaboration with the patient and famaiblyirb, .cwomho/te csta n visit and when.
- D. Permitting open visitation by adults 18 years of age and older; limit visits of children to 1 hour.
Correct Answer: C
Rationale: The correct answer is C because it reflects patient-centered care by involving patients and families in decision-making. Collaborating with them on visitation preferences promotes a supportive environment. Choice A restricts animal visitation, not addressing human visitors. Choice B limits visitation during specific times, not individualized. Choice D imposes restrictions based on age, not on patient/family preferences. Therefore, Choice C is the most aligned with current recommendations for open visitation policies.
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.
A critically ill patient is not expected to survive this admission. The family asks the nurse how the patient is doing. When answering this question, what should the nurse include?
- A. Emphasize that the patient is young and strong and may still survive.
- B. Refer the family to the physician for all details and answers.
- C. Give specific information such as descending trends in parameters.
- D. Ask if the family has determined which funeral home will be called.
Correct Answer: C
Rationale: The correct answer is C because providing specific information such as descending trends in parameters helps the family understand the patient's condition objectively. This allows them to prepare emotionally and make informed decisions. Option A is incorrect because false hope should not be given. Option B is not the best approach as the nurse should still provide some information to the family. Option D is inappropriate and insensitive as it focuses on funeral arrangements rather than addressing the family's concerns about the patient's condition.