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The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
- A. Wear the brace over a T-shirt 23 hours per day.
- B. Dress with the brace over regular clothing.
- C. Shower with the brace directly against the skin.
- D. Remove the brace just before going to bed.
Correct Answer: A
Rationale: The correct answer is A because wearing the Milwaukee brace over a T-shirt ensures proper skin protection and ventilation. This helps prevent skin irritation and allows for comfortable wearing for long periods. Choice B may cause skin issues due to friction. Choice C is incorrect as moisture from showering can lead to skin problems. Choice D is incorrect as consistent wear is crucial for brace effectiveness.
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A patient in a critical care unit has increased stress from the constant noise and light levels. What nursing intervention best attenuates these sources of stress?
- A. Need for constant observation and evaluation
- B. Dimming lights during the night
- C. Frequent nursing group rounds for all patients
- D. Use of tile floors for ease in cleaning
Correct Answer: B
Rationale: The correct answer is B: Dimming lights during the night. This intervention helps reduce stress by creating a more calming environment, promoting rest and sleep. Constant observation (choice A) may increase stress due to lack of privacy. Frequent group rounds (choice C) may disrupt rest. Use of tile floors (choice D) is unrelated to addressing noise and light stress.
What must the patient must be able of in order to provide informed consent?
- A. Be capable of independent breathing.
- B. Have knowledge and competence to make the decision .
- C. Nod head to agree to the procedure.
- D. Both read and write in English.
Correct Answer: B
Rationale: The correct answer is B because informed consent requires the patient to have knowledge and competence to make a decision. This involves understanding the risks, benefits, and alternatives of the proposed treatment. Choice A is incorrect as it pertains to a physical ability unrelated to decision-making. Choice C is incorrect as consent must be verbal or written, not just nodding. Choice D is incorrect as consent can be obtained in various ways, not specifically through reading and writing in English.
The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
- A. Check quickly for possible causes of the alarm that can be fixed.
- B. After troubleshooting, connect back to mechanical venti lator and reassess patient.
- C. Go to patient’s bedside.
- D. Manually ventilate the patient while getting respiratory therapist.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.
Which action by the nurse demonstrates cultural sensitivity in end-of-life care?
- A. Ensuring all patients receive the same standardized care.
- B. Avoiding discussions about death to prevent discomfort.
- C. Inquiring about specific cultural rituals and preferences.
- D. Advising families to follow hospital guidelines strictly.
Correct Answer: C
Rationale: The correct answer is C because inquiring about specific cultural rituals and preferences shows respect for the patient's cultural beliefs and values. By asking about these aspects, the nurse can provide care that aligns with the patient's cultural background, promoting comfort and understanding. This action also demonstrates a commitment to individualized care.
Choice A is incorrect because standardized care may not always be culturally appropriate. Choice B is incorrect as avoiding discussions about death can hinder effective communication and support. Choice D is incorrect as advising families to strictly follow hospital guidelines may overlook the importance of cultural considerations in end-of-life care.
A client with osteoarthritis is given a new prescription for a nonsteroidal anti-inflammatory drug (NSAID). The client asks the nurse, 'How is this medication different from the acetaminophen I have been taking?' Which information about the therapeutic action of NSAIDs should the nurse provide?
- A. Are less expensive.
- B. Provide anti-inflammatory response.
- C. Increase hepatotoxic side effects.
- D. Cause gastrointestinal bleeding.
Correct Answer: B
Rationale: The correct answer is B: Provide anti-inflammatory response. NSAIDs work by inhibiting the enzyme cyclooxygenase, thereby reducing inflammation, pain, and fever. This is different from acetaminophen, which primarily acts as a pain reliever and fever reducer but lacks significant anti-inflammatory properties.
Explanation of why other choices are incorrect:
A: Are less expensive - Cost is not related to the therapeutic action of NSAIDs.
C: Increase hepatotoxic side effects - While NSAIDs can have adverse effects on the liver, hepatotoxicity is not a primary therapeutic action of these drugs.
D: Cause gastrointestinal bleeding - While NSAIDs can increase the risk of gastrointestinal bleeding, this is a potential side effect rather than the primary therapeutic action.