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The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?
- A. Contact the attending physician immediately to determ ine if CPR should be initiated.
- B. Contact the family immediately to determine if they waabnirtb .CcoPmR/te stot be started.
- C. Give emergency medications but withhold intubation.
- D. Initiate CPR and call a code.
Correct Answer: D
Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.
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When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87°F (30.6°C), which assessment indicates that the nurse should discontinue active rewarming?
- A. The patient begins to shiver.
- B. The BP decreases to 86/42 mm Hg.
- C. The patient develops atrial fibrillation.
- D. The core temperature is 94°F (34.4°C).
Correct Answer: D
Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94°F (34.4°C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.
What is true regarding pain and anxiety in the healthy individual? (Select all that apply.)
- A. They activate the sympathetic nervous system.
- B. They decrease stress levels.
- C. They help remove one from harm.
- D. They increase performance levels.
Correct Answer: A
Rationale: The correct answer is A because pain and anxiety trigger the sympathetic nervous system's fight-or-flight response, increasing heart rate, blood pressure, and stress hormones to prepare the body for potential danger. This physiological response helps the individual respond to perceived threats. Choices B, C, and D are incorrect because pain and anxiety typically increase stress levels, do not necessarily remove one from harm, and can hinder rather than enhance performance due to distraction and decreased focus.
A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and
- A. The primary health care provider has approached the spouse regarding placement of a perma nent feeding tube. The spouse states that the patient never wanted to be kept alive by tub es and personally didn’t want what was being done. After holding a family conference with th e spouse, the medical team concurs and the feeding tube is not placed. What term would be used to describe this situation?
- B. Euthanasia
- C. Palliative care
- D. Withdrawal of life support
Correct Answer: E
Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes.
Step 2: The decision aligns with the principle of respecting patient autonomy.
Step 3: The term that best describes this situation is "Advance Directive."
Summary:
- A: Incorrect, as it involves actively ending the patient's life without their consent.
- B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering.
- C: Incorrect, as palliative care focuses on improving quality of life for the patient.
- D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.
The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s living will to the hospital, which identifies the patient’s wiasbhireb.sc orme/gteasrt ding health care. The nurse discusses the contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Pr ofessional Performance?
- A. Acquires and maintains current knowledge of practice
- B. Acts ethically on the behalf of the patient and family
- C. Considers factors related to safe patient care
- D. Uses clinical inquiry and integrates research findings i n practice
Correct Answer: C
Rationale: The correct answer is C: Considers factors related to safe patient care. The scenario involves the nurse discussing the patient's living will with the physician, which is essential for ensuring safe patient care by following the patient's preferences. This aligns with the AACN standard of considering factors related to safe patient care, as the nurse is actively involving all relevant parties in decision-making to provide care that is in line with the patient's wishes.
Explanation of why other choices are incorrect:
A: Acquires and maintains current knowledge of practice - While important, this choice does not directly relate to the scenario where the focus is on safe patient care through communication and collaboration.
B: Acts ethically on behalf of the patient and family - While ethics are important, the scenario is more about following the patient's wishes as outlined in the living will rather than making ethical decisions.
D: Uses clinical inquiry and integrates research findings in practice - While valuable in nursing practice, this choice does not directly apply to the scenario where
A patient is transferred to the ICU from the Birth Center of the hospital in the middle of the night after experiencing complications during delivery of her baby. The patients husband is anxious and explains to the ICU nurse that he doesnt understand why his wife has been moved to the ICU. She is going to die, isnt she? he asks the nurse. What is the nurses best response?
- A. Explain that every measure will be taken to provide his wife with the best care possible.
- B. Explain that the nurse is fully trained and has years of experience.
- C. Offer the husband a place to relax.
- D. Have appropriate staff discuss his health insurance with him.
Correct Answer: A
Rationale: The correct answer is A because it addresses the husband's concern directly by assuring him that every measure will be taken to provide the best care for his wife. This response shows empathy and provides reassurance, which is crucial in such a stressful situation. It helps to alleviate the husband's anxiety and fear by emphasizing the hospital's commitment to his wife's well-being.
Explanation for why the other choices are incorrect:
B: This response does not address the husband's immediate concern about his wife's well-being and may come across as dismissive.
C: Offering a place to relax does not address the husband's specific question and does not provide the information he is seeking.
D: Discussing health insurance is not appropriate at this moment of crisis and does not address the husband's fears about his wife's condition.