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The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathaibnirgb. ctohme/ tpesatt ient?
- A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure .
- B. Because the patient is unconscious, complete care as q uickly and quietly as possible.
- C. Inform the patient of the day and time, and what kind o f care you are providing.
- D. Turn the television on to the evening news so that you and the patient can be updated to current events.
Correct Answer: B
Rationale: The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive.
Explanation for other choices:
A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care.
C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient.
D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.
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The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?
- A. Antiseptic oral care
- B. Bed rest with head of bed elevated
- C. Coughing and deep breathing
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots.
A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism.
B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility.
C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.
The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient’s:
- A. Lipase.
- B. Temperature.
- C. Urinary output.
- D. Body mass index.
Correct Answer: B
Rationale: The correct answer is B: Temperature. Decreased ScvO2 in severe pancreatitis can be due to systemic inflammatory response leading to increased metabolic demand and decreased tissue oxygen delivery. Monitoring temperature helps assess for presence of infection or sepsis, which can further decrease tissue oxygenation. Lipase (A) is specific for pancreatitis diagnosis, not directly related to ScvO2. Urinary output (C) is important for assessing renal function, not directly related to ScvO2. Body mass index (D) does not provide information on tissue oxygenation status in this context.
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.
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
- A. A patient with no pedal pulses.
- B. A patient with an open femur fracture.
- C. A patient with bleeding facial lacerations.
- D. A patient with paradoxical chest movements.
Correct Answer: D
Rationale: The correct answer is D: A patient with paradoxical chest movements. This indicates flail chest, a life-threatening condition where a segment of the chest wall moves independently from the rest.
1. Flail chest can lead to respiratory compromise and potential respiratory failure.
2. Immediate intervention is needed to stabilize the chest wall and support breathing.
3. Without prompt treatment, the patient can develop hypoxia and potentially progress to cardiac arrest.
Summary:
- Choice A: No pedal pulses may indicate vascular compromise but does not pose an immediate threat to life.
- Choice B: Open femur fracture requires urgent treatment but does not have the same immediate life-threatening implications as flail chest.
- Choice C: Bleeding facial lacerations can be managed after addressing more critical injuries like flail chest.
The nurse is caring for a postoperative patient in the critica l care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands what facts about the PCA? (Select all that apply.)
- A. It is a safe and effective method for administering anal gesia.
- B. It has potentially fewer side effects than other routes of analgesic administration.
- C. It is an ideal method to provide critically ill patients so me control over their treatment.
- D. It does not work well without family assistance
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Patient-controlled analgesia (PCA) allows patients to self-administer pain medication within preset limits, promoting pain management.
2. PCA is considered safe and effective as it provides better pain control, reduces the risk of overdose, and allows for individualized dosing.
3. Healthcare providers can monitor and adjust the PCA settings as needed to ensure optimal pain relief.
4. Studies have shown that PCA is a preferred method for postoperative pain management due to its efficacy and safety profile.
5. Overall, PCA is a reliable and beneficial approach to analgesia administration in postoperative patients.
Summary of why other choices are incorrect:
B: While PCA may have fewer side effects compared to some routes, this is not a defining characteristic of PCA.
C: While patients do have some control over their treatment with PCA, the primary focus is on pain management rather than giving control to critically ill patients.
D: PCA can be used effectively without family