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The nurse wishes to assess the quality of a patient’s pain. Which questions is appropriate to obtain this assessment if the patient is able to give a verbal response?
- A. “Is the pain constant or intermittent?”
- B. “Is the pain sharp, dull, or crushing?”
- C. “What makes the pain better? Worse?”
- D. “When did the pain start?”
Correct Answer: B
Rationale: The correct answer is B because asking if the pain is sharp, dull, or crushing helps assess the quality of pain, providing specific information on the type of sensation felt. This is crucial for understanding the underlying cause and guiding appropriate treatment.
A: Asking about pain being constant or intermittent addresses duration, not quality.
C: Inquiring about what makes pain better or worse focuses on triggers, not quality.
D: Asking when the pain started addresses onset time, not quality.
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The nurse is caring for a patient receiving benzodiazepine intermittently. What is the best way to administer such drugs?
- A. Medicate around the clock, rather than as needed, to en sure constant sedation.
- B. Administer the medications through the feeding tube to prevent complications.
- C. Give the highest allowable dose for the greatest effect.
- D. Titrate to a predefined endpoint using a standard sedat ion scale.
Correct Answer: D
Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects.
A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects.
B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications.
C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?
- A. Antiseptic oral care
- B. Bed rest with head of bed elevated
- C. Coughing and deep breathing
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots.
A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism.
B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility.
C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.
A nurse who has been recently hired to manage the nursing staff of the ICU is concerned at the lack of evidence-based practice she sees among the staff. Which of the following would be the best step for her to take to promote incorporating evidence into clinical practice?
- A. Only hire nurses certified in critical care nursing.
- B. Leave copies of several different nursing journals in the nurses lounge.
- C. Demonstrate to the staff the best nursing-related search terms to use in Google orYahoo!
- D. Introduce the staff to the PubMed search engine and assign them topics to researchon it.
Correct Answer: D
Rationale: The correct answer is D because introducing the staff to the PubMed search engine and assigning them topics to research on it is the most effective way to promote evidence-based practice. PubMed is a reputable database that contains a vast collection of peer-reviewed articles and research studies, making it a reliable source for evidence. By assigning specific topics, the nurse can ensure that the staff is focusing on relevant and current information, fostering a deeper understanding of evidence-based practice.
Choice A is incorrect because certification in critical care nursing does not guarantee a commitment to evidence-based practice. Choice B is not as effective as it relies on passive exposure to journals rather than active engagement with specific research topics. Choice C is not the best option as using general search terms on search engines like Google or Yahoo may lead to unreliable or outdated information.
A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?
- A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
- B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
- C. Encourage the family to request that the physician evaluate the patients pain control.
- D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C
Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.
Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.
The nurse is caring for a postoperative patient in the critica l care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands what facts about the PCA? (Select all that apply.)
- A. It is a safe and effective method for administering anal gesia.
- B. It has potentially fewer side effects than other routes of analgesic administration.
- C. It is an ideal method to provide critically ill patients so me control over their treatment.
- D. It does not work well without family assistance
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct:
1. Patient-controlled analgesia (PCA) allows patients to self-administer pain medication within preset limits, promoting pain management.
2. PCA is considered safe and effective as it provides better pain control, reduces the risk of overdose, and allows for individualized dosing.
3. Healthcare providers can monitor and adjust the PCA settings as needed to ensure optimal pain relief.
4. Studies have shown that PCA is a preferred method for postoperative pain management due to its efficacy and safety profile.
5. Overall, PCA is a reliable and beneficial approach to analgesia administration in postoperative patients.
Summary of why other choices are incorrect:
B: While PCA may have fewer side effects compared to some routes, this is not a defining characteristic of PCA.
C: While patients do have some control over their treatment with PCA, the primary focus is on pain management rather than giving control to critically ill patients.
D: PCA can be used effectively without family