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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.
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Which of the following nursing activities demonstrates im plementation of the AACN Standards of Professional Performance? (Select all that ap ply.)
- A. Attending a meeting of the local chapter of the Americ an Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught
- B. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family
- C. Participating on the unit’s nurse practice council
- D. Posting an article from Critical Care Nurse on manage ment of venous thromboembolism for your colleagues to read
Correct Answer: C
Rationale: The correct answer is C because participating on the unit's nurse practice council demonstrates adherence to the AACN Standards of Professional Performance, specifically the standard related to quality of practice. By actively engaging in the nurse practice council, the nurse contributes to the development and implementation of policies and procedures that promote quality patient care. This activity also involves collaboration, leadership, and advocacy, which are essential components of professional nursing practice.
The other choices are incorrect because:
A: Attending a meeting and receiving continuing education on sepsis is important for professional development but does not directly align with the AACN Standards of Professional Performance.
B: Collaborating with a pastoral services colleague is essential for holistic patient care but does not specifically address the standards set by the AACN.
D: Posting an article for colleagues to read is beneficial for knowledge sharing but does not directly demonstrate adherence to the AACN Standards of Professional Performance.
To prevent any unwanted resuscitation after life-sustaininga btirrbe.acotmm/teenstt s have been withdrawn, the nurse should ensure that what intervention has been im plemented?
- A. Do-not-resuscitate (DNR) orders are written before dis continuation of the treatments.
- B. The family is not allowed to visit until the death occur s.
- C. DNR orders are written as soon as possible after the di scontinuation of the treatments.
- D. The change-of-shift report includes the information thaatb irtbh.ceo pma/tetiset nt is not to be resuscitated.
Correct Answer: A
Rationale: The correct answer is A because writing DNR orders before discontinuation of life-sustaining treatments ensures clear communication and legal documentation of the patient's wishes. Choice B is incorrect as family support is essential in end-of-life care. Choice C is incorrect as DNR orders should be established before withdrawing treatment. Choice D is incorrect as the DNR order should be in place before shift change for immediate implementation if needed.
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 term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is
- A. oliguria.
- B. azotemia.
- C. acute kidney injury.
- D. prerenal disease.
Correct Answer: B
Rationale: The correct answer is B: azotemia. Azotemia refers to an increase in BUN and serum creatinine levels, indicating impaired kidney function. Oliguria (A) is a decrease in urine output, not specific to BUN and creatinine levels. Acute kidney injury (C) is a broader term encompassing various causes of kidney dysfunction, not specific to elevated BUN and creatinine. Prerenal disease (D) refers to conditions affecting blood flow to the kidneys, not directly related to elevated BUN and creatinine levels.
What strategies are appropriate for preventing deep vein tharboirbm.cbomo/steisst (DVT) and pulmonary embolus (PE) in an at-risk patient? (Select all that apply.) WWW .THENURSINGMASTERY.COM
- A. Graduated compression stockings
- B. Heparin or low–molecular weight heparin
- C. Sequential compression devices
- D. Strict bed rest
Correct Answer: A
Rationale: The correct answer is A: Graduated compression stockings. These stockings help prevent blood from pooling in the legs, reducing the risk of DVT and PE. They improve circulation and reduce venous stasis. Option B, heparin, is used for treatment, not prevention. Option C, sequential compression devices, help prevent DVT but are not as effective as compression stockings. Option D, strict bed rest, can actually increase the risk of DVT by reducing blood flow.