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The nurse is preparing for insertion of a pulmonary artery acbairtbh.ceotme/rte (sPt AC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)
- A. Allay the patient’s anxiety by providing information ab out the procedure.
- B. Ensure that a sterile field is maintained during the inse rtion procedure.
- C. Inflate the balloon during the procedure when indicated by the physician.
- D. Monitor the patient’s cardiac rhythm throughout the en tire procedure.
Correct Answer: B
Rationale: The correct answer is B: Ensure that a sterile field is maintained during the insertion procedure. This is the priority nursing action because maintaining a sterile field is crucial to prevent infection during the invasive procedure. The nurse must follow strict aseptic technique to reduce the risk of introducing bacteria into the patient's bloodstream. All other choices are incorrect: A: Addressing the patient's anxiety is important but not the priority during the insertion procedure. C: Inflating the balloon is a specific action that should be performed by the physician, not the nurse. D: While monitoring the patient's cardiac rhythm is important, ensuring the sterile field takes precedence to prevent complications.
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The nurse aware that a shortage of organs exists knows that which statement is true?
- A. Anyone who is comfortable approaching the family sh ould discuss the option of organ donation.
- B. Brain death determination is required before organs ca n be retrieved for transplant.
- C. Donation of selected organs after cardiac death is ethically acceptable.
- D. Family members should consider withdrawing life supapboirbrt.c osmo /ttehsat t the patient can become an organ donor.
Correct Answer: B
Rationale: Rationale for Correct Answer (B - Brain death determination is required before organs can be retrieved for transplant):
1. Brain death determination is a medical necessity to ensure the organs are viable for transplant.
2. Organs must be retrieved promptly after brain death to maintain their functionality.
3. Brain death criteria ensure that the donor is truly deceased before organ retrieval.
Summary of Why Other Choices are Incorrect:
A: While discussing organ donation is important, comfort level is not the main factor in organ shortage awareness.
C: Donation after cardiac death is ethically acceptable, but it is not directly related to the need for brain death determination.
D: Withdrawing life support solely to become an organ donor is ethically questionable and not a necessary step in organ donation.
The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?
- A. The sister is in the way of the health care providers.
- B. The patient may become annoyed by her continual presence.
- C. The patient will recover more easily in peace and quiet.
- D. The sister needs to maintain her own health during this time.
Correct Answer: D
Rationale: The correct answer is D: The sister needs to maintain her own health during this time. It is essential for the sister to take care of her own health and well-being to be able to provide the best support to the patient. Continuous stress and lack of rest can negatively impact her ability to support the patient effectively. Encouraging her to rest will ensure she remains physically and mentally well to continue supporting the patient in the long run.
Incorrect Choices:
A: The sister is in the way of the health care providers - This is incorrect as the primary concern is the well-being of the sister and her ability to provide support.
B: The patient may become annoyed by her continual presence - This is not the main reason for suggesting the sister to rest, as the focus is on her own health.
C: The patient will recover more easily in peace and quiet - While peace and quiet can be beneficial for the patient, the main focus here is on the sister's well-being.
Which statement about family assessment is false?
- A. Assessment of structure (who comprises the family) is the last step in assessment.
- B. Interaction among family members is assessed.
- C. It is important to assess communication among family members to understand roles.
- D. Ongoing assessment is important, because family funcatbioirbn.cinomg/ tmesat y change during the course of illness.
Correct Answer: A
Rationale: The correct answer is A because assessing the structure of the family (who comprises the family) is not the last step in family assessment. The rationale is that understanding the family structure is essential at the beginning of the assessment process to identify key relationships and support systems. Assessing interaction among family members helps to understand dynamics and relationships within the family. Assessing communication is crucial to identify roles and patterns of interaction. Ongoing assessment is necessary as family dynamics can evolve throughout the illness. Therefore, A is false as family structure assessment is an important initial step, not the last step.
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.
A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly anxious and fidgets with his IV constantly. He complains that he doesnt want to be there and he is sick of everyone telling him what to do. What would be the best way for the nurse to address this patients anxiety?
- A. Use physical restraints to keep him from pulling out his IV.
- B. Offer him the remote to the television.
- C. Lower the head of his bed so that he can rest more easily.
- D. Explain to the patient in detail what the appendectomy will consist of.
Correct Answer: B
Rationale: The correct answer is B: Offer him the remote to the television. This is the best way to address the patient's anxiety because it provides a distraction and a sense of control, which can help alleviate anxiety. By offering the patient the remote to the television, the nurse is giving him a choice and a way to focus his attention away from his anxiety. This can help him feel more comfortable and empowered in the situation.
Choice A is incorrect because using physical restraints can increase the patient's anxiety and sense of helplessness. Choice C, lowering the head of his bed, may provide physical comfort but does not directly address his anxiety. Choice D, explaining the procedure in detail, may further increase his anxiety as it focuses on the surgery rather than addressing his current emotional state.