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The nurse is caring for a patient receiving benzodiazepine intermittently. What is the best way to administer such drugs?
- A. Medicate around the clock, rather than as needed, to en sure constant sedation.
- B. Administer the medications through the feeding tube to prevent complications.
- C. Give the highest allowable dose for the greatest effect.
- D. Titrate to a predefined endpoint using a standard sedat ion scale.
Correct Answer: D
Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects.
A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects.
B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications.
C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.
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The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should
- A. draw a trough level after the next dose of antibiotic.
- B. obtain an order to place the patient on fluid restriction.
- C. assess the patient’s lungs.
- D. insert an indwelling catheter.
Correct Answer: C
Rationale: First, the nurse should assess the patient's lungs to rule out any potential respiratory issues causing fluid retention. This is crucial as the patient has signs of fluid imbalance with decreased output and increased weight. Assessing the lungs can help identify conditions like heart failure or pneumonia that may contribute to these changes. Drawing a trough level (choice A) is not a priority as it doesn't address the immediate concern of fluid imbalance. Placing the patient on fluid restriction (choice B) should only be done after identifying the cause of the imbalance. Inserting an indwelling catheter (choice D) is not necessary at this point as the issue is related to fluid balance, not urinary elimination.
The nurse manager recognizes which action as an effectiveab sirtbr.acotmeg/teys tf or promoting changes in practice?
- A. Asking the clinical nurse specialist to lead a journal clu b on open visitation after each nurse is tasked to read one research article about visitation.
- B. Discussing pros and cons of open visitation at the next staff meeting.
- C. Inviting the nurses with the most experience to develop a revised policy.
- D. Tasking the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberaal bviribs.ciotamt/iteosnt .
Correct Answer: A
Rationale: The correct answer is A because it involves a structured approach to promoting changes in practice. By asking the clinical nurse specialist to lead a journal club on open visitation after each nurse reads a research article, it ensures that all nurses are informed and engaged in the topic. This approach promotes evidence-based practice and encourages active participation.
Option B is less effective as discussing pros and cons at a staff meeting may not ensure that all nurses have the necessary knowledge to make informed decisions. Option C may not consider diverse perspectives and may not involve all staff members equally. Option D involves a select group of volunteers and may not reflect the views of the entire team. Overall, option A is the most inclusive and educational approach to promoting changes in practice.
A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?
- A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
- B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
- C. Encourage the family to request that the physician evaluate the patients pain control.
- D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C
Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.
Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.
The nurse is assisting with endotracheal intubation and un derstands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.)
- A. Auscultation of air over the epigastrium
- B. Equal bilateral breath sounds upon auscultation
- C. Position above the carina verified by chest x-ray
- D. Positive detection of carbon dioxide (CO
Correct Answer: B
Rationale: The correct answer is B: Equal bilateral breath sounds upon auscultation. This indicates proper placement of the endotracheal tube in the trachea, ensuring both lungs are being ventilated equally.
Rationale:
1. Auscultation of air over the epigastrium (Choice A) is incorrect as it indicates esophageal intubation, not tracheal intubation.
2. Position above the carina verified by chest x-ray (Choice C) is incorrect as it does not confirm proper placement at the trachea.
3. Positive detection of carbon dioxide (CO2) (Choice D) is incorrect as it indicates the presence of exhaled CO2, but not necessarily proper placement in the trachea.
A nurse walks into a patients room and begins preparing a syringe to perform a blood draw on the patient. The nurse observes that the patient is firmly gripping the side of the bed, averting her eyes, and sweating from her forehead when she sees the needle. What would be the best intervention for the nurse to make?
- A. Proceed with blood draw as quickly as possible, to get it over with.
- B. Offer to come back later to perform the blood draw.
- C. Encourage the patient to deep breathe.
- D. Describe briefly the blood draw procedure and explain why it is necessary.
Correct Answer: D
Rationale: The correct answer is D because it shows empathy and promotes patient education. By describing the procedure and its necessity, the nurse can alleviate the patient's anxiety and build trust. This approach allows the patient to feel informed and in control, reducing fear and increasing cooperation. It also demonstrates respect for the patient's feelings and promotes a therapeutic relationship.
Choice A is incorrect as it disregards the patient's fear and can lead to increased distress. Choice B might be an option, but it doesn't address the patient's anxiety in the moment. Choice C, while helpful in some cases, doesn't directly address the patient's specific fear of the blood draw procedure.