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What is the best way to monitor agitation and effectivenes s of treating it in the critically ill patient?
- A. Confusion Assessment Method (CAM-ICU)
- B. FACES assessment tool
- C. Glasgow Coma Scale
- D. Richmond Agitation Sedation Scale
Correct Answer: D
Rationale: The correct answer is D: Richmond Agitation Sedation Scale (RASS). RASS is specifically designed to monitor agitation and sedation levels in critically ill patients, providing a standardized and objective assessment. It includes clear descriptors for different levels of agitation and sedation, allowing for consistent monitoring and treatment adjustments. CAM-ICU is mainly used for delirium assessment, not agitation. FACES assessment tool is more appropriate for pain assessment. Glasgow Coma Scale is focused on assessing level of consciousness, not agitation specifically. By using RASS, healthcare providers can accurately track agitation levels and evaluate the effectiveness of interventions in managing agitation in critically ill patients.
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A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving:
- A. Tetanus immunoglobulin (TIG) only.
- B. TIG and tetanus-diphtheria toxoid (Td).
- C. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only.
- D. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
Correct Answer: D
Rationale: The correct answer is D because the patient has a high-risk wound (tissue avulsion) and no documented prior tetanus vaccination. TIG provides immediate passive immunity to tetanus, while Tdap stimulates active immunity. TIG covers immediate needs, while Tdap ensures long-term immunity. Choice A (TIG only) does not provide long-term immunity. Choice B (TIG and Td) does not include pertussis coverage, which Tdap (Choice D) does. Choice C (Tdap only) does not cover immediate needs as TIG does.
The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the family about withdrawing life support. Which statemen t by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation?
- A. “I need to notify the organ procurement organization O PO of my patient’s impending death.”
- B. “I will contact the physician to obtain informed consen t for organ donation.”
- C. “The charge nurse will notify organ procurement organization OPO once the patient has been pronounced brain dead.”
- D. “I need the physician to evaluate my patient’s suitability for organ donation.”
Correct Answer: C
Rationale: The correct answer is C because notifying the organ procurement organization (OPO) once the patient has been pronounced brain dead is a requirement to sustain CMS Conditions of Participation. This step ensures that the proper protocols are followed for organ donation.
Choice A is incorrect because notifying the OPO of impending death is not a requirement for sustaining CMS Conditions of Participation.
Choice B is incorrect because obtaining informed consent for organ donation is not directly related to meeting the requirements of CMS Conditions of Participation.
Choice D is incorrect because while evaluating the patient's suitability for organ donation is important, it is not a specific requirement under CMS Conditions of Participation.
The AACN Standards for Acute and Critical Care Nursing Practice uses what framework to guide critical care nursing practice?
- A. Evidence-based practice
- B. Healthy work environment
- C. National Patient Safety Goals
- D. Nursing process
Correct Answer: A
Rationale: The correct answer is A: Evidence-based practice. The AACN Standards for Acute and Critical Care Nursing Practice emphasize the use of evidence-based practice to guide critical care nursing. This framework ensures that nursing interventions are based on the best available evidence, leading to improved patient outcomes. Healthy work environment (B) and National Patient Safety Goals (C) are important but not specific frameworks for critical care nursing. The nursing process (D) is a systematic approach to delivering patient care but is not the primary guiding framework in critical care nursing practice.
Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis
- A. is more frequently used for acute kidney injury.
- B. uses the patient’s own semipermeable membrane (peritoneal membrane).
- C. is not useful in cases of drug overdose or electrolyte imbalance.
- D. is not indicated in cases of water intoxication.
Correct Answer: B
Rationale: The correct answer is B because peritoneal dialysis utilizes the patient's own semipermeable membrane, the peritoneal membrane, as the filtration surface. This allows for the exchange of waste products and excess fluids without the need for external dialysis equipment. Choice A is incorrect as peritoneal dialysis can be used for both acute and chronic kidney injury. Choice C is incorrect as peritoneal dialysis can help manage drug overdose and electrolyte imbalances. Choice D is incorrect as peritoneal dialysis can be used in cases of water intoxication to help remove excess fluids.
The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.)
- A. bladder catheterization.
- B. increasing fluid volume intake.
- C. ureteral stenting.
- D. placement of nephrostomy tubes.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Bladder catheterization helps relieve urinary obstruction, a common postrenal cause of acute kidney injury.
2. By draining urine from the bladder, it prevents further damage to the kidneys.
3. This intervention addresses the underlying cause of the kidney injury, leading to improvement.
Summary:
- Choice A is correct as it directly addresses the postrenal cause by relieving urinary obstruction.
- Choices B, C, and D are incorrect as they do not target the specific postrenal cause of acute kidney injury.