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The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next?
- A. Explain ICU visitation policies and encourage family visits.
- B. Immediately take the family members to the patient’s bedside.
- C. Describe the patient’s injuries and the care that is being provided.
- D. Invite the family to participate in a multidisciplinary care conference.
Correct Answer: A
Rationale: The correct answer is A: Explain ICU visitation policies and encourage family visits. This is the best course of action because it prioritizes the needs of the family members by providing them with information on visitation policies and encouraging them to visit the patient. This helps establish communication, support, and involvement in the patient's care. It also respects the family's emotional needs during a challenging time.
Choices B, C, and D are incorrect:
B: Immediately taking the family members to the patient's bedside may overwhelm them and disrupt the patient's care.
C: Describing the patient's injuries and care being provided should be done in a more controlled environment to ensure the family's understanding and emotional readiness.
D: Inviting the family to a multidisciplinary care conference may be premature without first addressing their immediate concerns and providing support.
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The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should
- A. prepare to assist with a routine dialysis catheter change.
- B. evaluate the patient for signs and symptoms of infection.
- C. teach the patient that the catheter is designed for long-term use.
- D. use one of the three lumens for fluid administration.
Correct Answer: B
Rationale: The correct answer is B because after 5 days, the risk of infection increases. Evaluating the patient for signs and symptoms of infection is crucial for early detection and treatment. Choice A is incorrect because routine dialysis catheter changes are not necessary after only 5 days. Choice C is incorrect as percutaneous catheters are for short-term use. Choice D is incorrect as using the catheter for fluid administration may increase the risk of infection.
A patient in the ICU has recently been diagnosed with diabetes mellitus. Before being discharged, this patient will require detailed instructions on how to manage her diet, how to self-inject insulin, and how to handle future diabetic emergencies. Which nurse competency is most needed in this situation?
- A. Clinical judgment
- B. Advocacy and moral agency
- C. Caring practices
- D. Facilitation of learning
Correct Answer: D
Rationale: The correct answer is D: Facilitation of learning. In this scenario, the nurse needs to effectively educate the patient on managing her diet, insulin injections, and handling emergencies. Facilitation of learning involves assessing the patient's learning needs, providing relevant information, demonstrating skills, and evaluating understanding. This competency is crucial for promoting patient education and empowerment in managing their condition.
A: Clinical judgment involves making decisions based on assessment data, which is important but not the primary focus in this situation.
B: Advocacy and moral agency involve standing up for patients' rights and values, which is important but not as directly relevant to the patient's education needs.
C: Caring practices involve showing empathy and compassion, which are essential but not the main competency required for educational purposes in this case.
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces th e risk of catheter-related bloodstream infection (CRBSI)?
- A. Review daily the necessity of the central venous cathet er.
- B. Cleanse the insertion site daily with isopropyl alcohol.
- C. Change the pressurized tubing system and flush bag daily.
- D. Maintain a pressure of 300 mm Hg on the flush bag.
Correct Answer: A
Rationale: The correct answer is A: Review daily the necessity of the central venous catheter. This action reduces the risk of CRBSI by promoting early removal of unnecessary catheters, which is a key strategy in preventing infections. Unnecessary catheters increase the risk of infection due to prolonged exposure to the patient's skin flora and possible contamination during insertion. Reviewing daily ensures the catheter is only kept when necessary, minimizing the duration of catheter use and reducing the chances of infection.
Summary of other choices:
B: Cleansing the insertion site daily with isopropyl alcohol is important for maintaining skin integrity but does not directly reduce the risk of CRBSI.
C: Changing the pressurized tubing system and flush bag daily is important for maintaining catheter patency but does not directly reduce the risk of CRBSI.
D: Maintaining a pressure of 300 mm Hg on the flush bag is important for proper catheter function but does not directly reduce the risk of CR
Following surgery for an abdominal aortic aneurysm, the patient’s central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?
- A. Administer IV diuretic medications.
- B. Increase the IV fluid infusion per protocol.
- C. Document the CVP and continue to monitor.
- D. Elevate the head of the patient's bed to 45 degrees.
Correct Answer: B
Rationale: The correct answer is B: Increase the IV fluid infusion per protocol. Low CVP post-abdominal aortic aneurysm surgery could indicate hypovolemia, which requires fluid resuscitation. Increasing IV fluid infusion helps restore intravascular volume, improve tissue perfusion, and prevent hypotension. Administering diuretics (A) would worsen hypovolemia. Documenting (C) is important but not the priority when the patient needs immediate intervention. Elevating the head of the bed (D) may help with venous return but is not the priority over addressing hypovolemia.
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.