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The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the aaibri-rbf.lcuoimd/ teinstt erface is at the level of the phlebostatic axis, what is the best nursing action?
- A. Place the patient in the supine position and record the PAOP immediately after exhalation.
- B. Place the patient in the supine position and document the average PAOP obtained after three measurements.
- C. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained.
- D. Place the patient with the head of bed elevated 30 degr ees and record the PAOP just before the increase in pressures during inhalation.
Correct Answer: C
Rationale: The correct answer is C because placing the patient with the head of the bed elevated 30 degrees is the best position for obtaining an accurate PAOP reading. Elevating the head of the bed helps to align the phlebostatic axis with the atrium, ensuring an accurate measurement of PAOP. This position reduces the impact of hydrostatic pressure on the reading. Options A and D are incorrect because the supine position and recording during exhalation or just before the increase in pressures during inhalation can lead to inaccurate readings. Option B is incorrect because documenting the average PAOP after three measurements does not address the importance of positioning for accuracy.
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A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should resultf rom these measures?
- A. Identification of incompetent practitioners
- B. Improvement in manners on the unit
- C. Increased staff retention
- D. Less discussion in front of patients and families
Correct Answer: C
Rationale: Rationale:
- Improved collaboration enhances job satisfaction and reduces burnout, leading to increased staff retention.
- Higher staff retention promotes continuity of care, improves team dynamics, and enhances patient outcomes.
Summary:
- A: Not directly related to collaboration, more about performance evaluation.
- B: Manners may improve, but not the most important effect of collaboration.
- D: Collaboration involves open communication, so less discussion in front of patients is not a positive outcome.
The nurse is caring for a mechanically ventilated patient. T he primary care providers are considering performing a tracheostomy because the patienatb iirsb .hcoamv/itensgt difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following?
- A. Patient outcomes are better if the tracheostomy is done within a week of intubation.
- B. Percutaneous tracheostomy can be done safely at the b edside by the respiratory therapist.
- C. Procedures performed in the operating room are associaabtirebd.c owmi/ttehs tf ewer complications.
- D. The greatest risk after a percutaneous tracheostomy is accidental decannulation.
Correct Answer: C
Rationale: The correct answer is C: Procedures performed in the operating room are associated with fewer complications. This is because performing a tracheostomy in the operating room allows for better control of the environment, equipment, and expertise of the surgical team. In this setting, the risk of complications such as bleeding, infection, and injury to surrounding structures is minimized.
Choices A, B, and D are incorrect:
A: Patient outcomes are better if the tracheostomy is done within a week of intubation - This statement is not universally true and depends on individual patient factors. Timing of tracheostomy should be based on the patient's clinical condition and not a set timeline.
B: Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist - While percutaneous tracheostomy can be performed at the bedside, it is typically done by a trained physician or surgeon due to the potential risks and complications involved.
D: The greatest risk after a per
A nurse who plans care based on the patient’s gender, ethn ai bc iri bt .y co, ms /p tei sr ti tuality, and lifestyle is said to demonstrate what focus?
- A. Becoming a moral advocate.
- B. Facilitating all forms of learning.
- C. Responding to diversity.
- D. Using effective clinical judgment.
Correct Answer: C
Rationale: The correct answer is C: Responding to diversity. By considering the patient's gender, ethnicity, spirituality, and lifestyle, the nurse is focusing on responding to diversity in patient care. This approach acknowledges and respects the unique characteristics and backgrounds of individual patients, leading to more culturally competent and effective care.
Choice A: Becoming a moral advocate does not directly relate to considering diversity in patient care. It involves standing up for ethical principles and values in healthcare.
Choice B: Facilitating all forms of learning is not specific to addressing diversity in patient care. It pertains to promoting education and understanding in various learning styles.
Choice D: Using effective clinical judgment is important in nursing practice but does not specifically address the focus on diversity in patient care. It pertains to making sound decisions based on clinical knowledge and expertise.
Which nursing actions are most important for a patient witahb irab .croigmh/tte srta dial arterial line? (Select all that apply.)
- A. Checking the circulation to the right hand every 2 hour s
- B. Maintaining a pressurized flush solution to the arterial line setup
- C. Monitoring the waveform on the monitor for dampenin g
- D. Restraining all four extremities with soft limb restraint s
Correct Answer: A
Rationale: Step 1: Checking circulation to the right hand is crucial for assessing perfusion and detecting potential complications.
Step 2: Arterial line placement can compromise blood flow, leading to ischemia if circulation is impaired.
Step 3: Monitoring circulation every 2 hours allows for early detection of issues and prompt intervention.
Step 4: This action ensures patient safety and prevents complications.
Summary:
- Choice B is incorrect as pressurized flush solution can increase the risk of complications.
- Choice C is incorrect as monitoring the waveform is important but not the most critical action.
- Choice D is incorrect as limb restraints can impede circulation and are unnecessary in this scenario.
The nurse uses subtle measures of painful stimuli, such as nailbed pressure to elicit a response from a neurologically impaired patient. By using this meth od rather than nipple pinching, the nurse is exemplifying what ethical principle?
- A. Beneficence
- B. Fidelity
- C. Nonmaleficence
- D. Veracity
Correct Answer: C
Rationale: The correct answer is C: Nonmaleficence. The nurse is demonstrating nonmaleficence by choosing a less harmful method (nailbed pressure) to assess pain in a neurologically impaired patient, instead of a more painful method (nipple pinching). Nonmaleficence is the ethical principle of avoiding harm or minimizing harm to the patient. In this scenario, the nurse is prioritizing the well-being and comfort of the patient by using a less invasive and painful method to elicit a response. Choices A, B, and D are incorrect because beneficence refers to doing good for the patient, fidelity to being loyal and maintaining trust, and veracity to truthfulness and honesty, none of which directly apply in this situation.