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The nurse is concerned that the patient will pull out the en dotracheal tube. As part of the nursing management, the nurse should obtain an order for what intervention?
- A. A Posey-type vest
- B. A higher dosage of lorazepam
- C. Propofol
- D. Soft wrist restraints
Correct Answer: A
Rationale: The correct answer is A. A Posey-type vest is a restraint designed to prevent patients from pulling out medical devices like endotracheal tubes, ensuring their safety. It is a less restrictive option compared to wrist restraints and sedatives (B and C), which can have adverse effects and may not directly address the concern of tube removal. Using a Posey-type vest promotes patient autonomy by allowing some movement while still providing the necessary protection.
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Anxiety differs from pain in that way? (Select all that app ly.)
- A. Anxiety is confined to neurological processes in the brain.
- B. Anxiety is linked to reward and punishment centers in the limbic system.
- C. Anxiety is subjective; pain is not.
- D. Anxiety produces no actual tissue injury.
Correct Answer: B
Rationale: The correct answer is B because anxiety is indeed linked to reward and punishment centers in the limbic system, specifically involving the amygdala and prefrontal cortex. This connection influences emotional responses and behaviors related to anxiety. Choices A, C, and D are incorrect because anxiety involves both neurological and psychological processes beyond the brain, is highly subjective like pain, and can lead to physical symptoms without actual tissue injury.
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.
The nurse is caring for a mechanically ventilated patient w ith a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action?a birb.com/test
- A. Do not document hemodynamic values until the patient can be placed in the supine position.
- B. Level and zero reference the air-fluid interface of the t ransducer with the patient in the supine position and record hemodynamic values.
- C. Level and zero reference the air-fluid interface of the t ransducer with the patient’s head of bed elevated to 30 degrees and record hemodynamic values.
- D. Level and zero reference the air-fluid interface of the tarbainrbs.cdoumc/teers t with the patient supine in the side-lying position and record hemodynamic values.
Correct Answer: C
Rationale: Rationale: Option C is the correct answer because when caring for a patient with a pulmonary artery catheter receiving continuous enteral feedings, it is crucial to level and zero reference the transducer with the patient's head of bed elevated to 30 degrees. This position helps to ensure accurate hemodynamic measurements, as the head of bed elevation minimizes the impact of intra-abdominal pressure on the catheter readings. By referencing the transducer in this position, the nurse can obtain reliable and precise hemodynamic values.
Summary of Incorrect Choices:
A: This option is incorrect because delaying documentation until the patient is in the supine position can lead to inaccuracies in the hemodynamic readings due to changes in patient positioning.
B: Leveling and zero referencing the transducer with the patient in the supine position is not ideal as it does not account for the impact of intra-abdominal pressure on the catheter readings in patients receiving enteral feedings.
D: Leveling and zero referencing
After attending an educational program, the nurse understaanbidrbs.c othma/tte swt hich the following situations would require an ethics consultation?
- A. Conflict has occurred between the primary care provid er and family regarding treatment decisions. A family conference is held, and the family and primary care provider agree to a treatment plan that includes aggres sive treatment for 24 hours followed by re-evaluation.
- B. Family members disagree as to a patient’s course of tre atment. The patient has designated a healthcare proxy and has a written advancaebi rdb.icroemc/tteivste .
- C. A postoperative coronary artery bypass surgery patient was successfully resuscitated after sustaining a cardiopulmonary arrest i n the operating room The patient who is now not responding to treatment has a written advance directive and has a life partner at the bedside.
- D. Patient with multiple trauma and is not responding to treatment. No family members are known, and care is considered futile.
Correct Answer: D
Rationale: Step 1: The correct answer is D because the situation involves a patient with multiple trauma who is not responding to treatment and has no known family members. This indicates a complex ethical dilemma where the medical team may be unsure about the appropriate course of action.
Step 2: In this scenario, an ethics consultation is necessary to help guide decision-making regarding the care of the patient. The lack of available family members complicates decision-making, and the consideration of care as futile adds another layer of complexity.
Step 3: An ethics consultation can provide a structured framework for evaluating the situation, considering ethical principles such as beneficence, non-maleficence, autonomy, and justice. It can help the healthcare team navigate the ethical considerations and make a well-informed decision in the best interest of the patient.
Summary:
Choice A: While conflicts between the primary care provider and family may warrant discussions, the agreement on a treatment plan does not necessarily require an ethics consultation.
Choice B: Disagreement
A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action?
- A. Maintain the restraints to protect patient safety.
- B. Remove the restraints periodically to check skin integrity.
- C. Remove the restraints periodically for range of motion.
- D. Assess and intervene for causes of agitation. Answer Key
Correct Answer: D
Rationale: The correct answer is D: Assess and intervene for causes of agitation. In a critically ill patient, agitation while intubated could indicate underlying issues like pain, delirium, or inadequate sedation. By assessing and addressing the root cause of agitation, the nurse can improve patient comfort and prevent potential harm from restraints. Removing restraints periodically for skin integrity (B) and range of motion (C) is important but should not be the primary focus when agitation is present. Maintaining restraints (A) without addressing the agitation could lead to increased distress and potential complications.