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The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
- A. Tracheostomy tube suctioning.
- B. Medication administration.
- C. Colostomy care instruction.
- D. Client personal hygiene.
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.
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The nurse caring for a mechanically ventilated patient note s the high pressure alarm sounding but cannot quickly identify the cause of the alarm. The nurasbeir bn.cootme/ste stht e patient’s oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse’s priority action?
- A. Ask the respiratory therapist to get a new ventilator
- B. Call the rapid response team to assess the patient
- C. Continue to find the cause of the alarm and fix it
- D. Manually ventilate the patient while calling for a respi ratory therapist
Correct Answer: B
Rationale: The correct answer is B. The nurse's priority is to ensure the patient's safety and well-being. Calling the rapid response team will allow for immediate assessment by a team of healthcare professionals to address the deteriorating condition. This step takes precedence over troubleshooting the ventilator or manually ventilating the patient. Asking for a new ventilator (A) or manually ventilating the patient (D) does not address the urgent need for a comprehensive assessment and intervention. Continuing to troubleshoot the alarm (C) can delay critical interventions needed for the patient's worsening condition. Thus, calling the rapid response team is the most appropriate action to address the escalating clinical situation promptly.
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should:
- A. Inflate the cuff with a minimum of 10 mL of air.
- B. Inflate the cuff until the pilot balloon is firm on palpation.
- C. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
- D. Inject air into the cuff until a slight leak is heard only at peak inflation.
Correct Answer: D
Rationale: The correct answer is D because inflating the cuff until a slight leak is heard only at peak inflation ensures it is adequately sealed but not overinflated, preventing complications like tracheal injury or pressure necrosis. Choice A lacks specificity and can lead to overinflation. Choice B may result in overinflation as the firmness of the balloon is subjective. Choice C relies on a specific pressure reading, which may vary based on factors like tube size and patient anatomy, potentially leading to under- or overinflation.
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
- A. Assess the patient’s current vital signs.
- B. Give acetaminophen (Tylenol) per agency protocol.
- C. Ask the patient to provide clean-catch urine for urinalysis.
- D. Tell the patient that it will be 1 to 2 hours before being seen by the doctor.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention.
The other choices are incorrect because:
B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment.
C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case.
D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative?
- A. AACN expert panel report
- B. A meta-analysis of randomized controlled trials in the American Journal of Nursing
- C. A systematic review of qualitative studies in the Journal of Advanced Nursing
- D. A single randomized controlled trial in the American Journal of Critical Care
Correct Answer: B
Rationale: The correct answer is B: A meta-analysis of randomized controlled trials in the American Journal of Nursing.
1. Meta-analyses provide a comprehensive overview of multiple studies, increasing the reliability of the findings.
2. Randomized controlled trials are considered the gold standard in research design for assessing intervention effectiveness.
3. The American Journal of Nursing is a reputable source in the field of nursing, ensuring the credibility of the study.
4. By synthesizing data from various trials, the meta-analysis can offer a more robust and generalizable conclusion compared to a single trial or qualitative studies.
Incorrect choices:
A: AACN expert panel report - Expert opinions may vary and lack the empirical evidence provided by research studies.
C: A systematic review of qualitative studies in the Journal of Advanced Nursing - Qualitative studies may provide valuable insights but may not offer concrete evidence on intervention effectiveness like quantitative studies.
D: A single randomized controlled trial in the American Journal of Critical Care - Single trials may not capture the full picture and
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
- A. Stimulate contraction of the uterus.
- B. Initiate the lactation process.
- C. Facilitate maternal-infant bonding.
- D. Prevent neonatal hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A because breastfeeding helps stimulate the uterus to contract, which reduces the risk of postpartum hemorrhage in the mother. When the baby suckles at the breast, it triggers the release of oxytocin, a hormone that causes the uterus to contract. This contraction helps the uterus to return to its pre-pregnancy size and shape, promoting faster healing and reducing bleeding.
Choice B is incorrect because lactation initiation is a separate process that involves hormonal changes and milk production, which may not occur immediately after delivery. Choice C is incorrect as bonding can occur through various interactions beyond breastfeeding. Choice D is incorrect as neonatal hypoglycemia is primarily prevented by ensuring the baby receives adequate nutrition, which can also be achieved through other feeding methods besides breastfeeding.