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The nurse wishes to enhance sleep cycles in her critically ill patient. Research has shown that which nursing action improves sleep in critically ill patients?
- A. Repositioning every 2 hours
- B. Hypnotic medications
- C. Five-minute back effleurage
- D. Adequate pain control
Correct Answer: D
Rationale: The correct answer is D: Adequate pain control. Pain can significantly disrupt sleep in critically ill patients. By ensuring adequate pain control, the nurse can help improve the patient's ability to rest and sleep. This intervention targets a key factor affecting sleep cycles in critically ill patients. Repositioning every 2 hours (A) may help prevent pressure ulcers but does not directly address sleep improvement. Hypnotic medications (B) may have adverse effects and are not recommended as a first-line intervention. Five-minute back effleurage (C) may provide temporary relaxation but is not as effective as adequate pain control in improving sleep quality.
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assessment, the patient is restless, heart rate has increased to 110 beats/min, respirat ions are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sin us tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretio ns. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In comambirubn.ciocma/tteinstg with the physician, which statement indicates the nurse understands what is likely occurring with the patient?
- A. “May we have an order for cardiac enzymes? This pati ent is exhibiting signs of a myocardial infarction.”
- B. “My assessment indicates potential fluid overload.”
- C. “The patient is having frequent PVCs that are comprom ising the cardiac output.”
- D. “The patient is having a hypertensive crisis; what medications would you like to order?”
Correct Answer: B
Rationale: The correct answer is B: “My assessment indicates potential fluid overload.” The patient is showing signs of fluid overload, such as increased heart rate, respiratory rate, elevated blood pressure, pulmonary artery pressures, frothy secretions, and crackles in lung fields. These symptoms suggest fluid is accumulating in the lungs, causing pulmonary congestion. This can lead to impaired gas exchange and respiratory distress. The nurse's recognition of these signs is crucial for prompt intervention to prevent further complications. Other choices are incorrect because there are no indications of a myocardial infarction, PVCs compromising cardiac output, or a hypertensive crisis based on the given information.
One of the strategies shown to reduce perception of stress in critically ill patients and their families is support of spirituality. What nursing action is most clearly supportive of the patients spirituality?
- A. Referring patients to the Catholic chaplain
- B. Providing prayer booklets to patients and families
- C. Asking about beliefs about the universe
- D. Avoiding discussing religion with those of other faiths
Correct Answer: C
Rationale: The correct answer is C because asking about beliefs about the universe allows the nurse to understand the patient's spiritual needs and provide appropriate support. This action shows respect for the patient's beliefs and can help establish a connection between the patient and the nurse. Referring patients to a specific religious figure (choice A) may not align with the patient's beliefs. Providing prayer booklets (choice B) assumes the patient's belief system and may not be helpful. Avoiding discussing religion (choice D) can hinder the nurse-patient relationship and overlook potential sources of support for the patient.
A patient is declared brain dead and a do not resuscitate (DNR) order is put in place. The nurse caring for the patient does not agree with this manne r of care but does not express any concerns to the charge nurse. The nurse’s feeling that the p atient is being killed will likely create what response for this nurse?
- A. A sense of abandonment
- B. Increased family stress
- C. Moral distress
- D. A sense of negligence
Correct Answer: C
Rationale: The correct answer is C: Moral distress. In this scenario, the nurse is experiencing conflicting moral values between the decision made for the patient and their own beliefs. This internal conflict leads to moral distress, a common response when healthcare professionals feel unable to act in accordance with their ethical beliefs. This can lead to emotional turmoil, frustration, and moral residue.
A: A sense of abandonment is incorrect because the nurse is still caring for the patient, so there is no physical abandonment.
B: Increased family stress is incorrect as the nurse's internal conflict does not directly impact family stress.
D: A sense of negligence is incorrect as negligence implies failure to provide proper care, which is not the case here.
The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should
- A. prepare to assist with a routine dialysis catheter change.
- B. evaluate the patient for signs and symptoms of infection.
- C. teach the patient that the catheter is designed for long-term use.
- D. use one of the three lumens for fluid administration.
Correct Answer: B
Rationale: The correct answer is B because after 5 days, the risk of infection increases. Evaluating the patient for signs and symptoms of infection is crucial for early detection and treatment. Choice A is incorrect because routine dialysis catheter changes are not necessary after only 5 days. Choice C is incorrect as percutaneous catheters are for short-term use. Choice D is incorrect as using the catheter for fluid administration may increase the risk of infection.
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best inter pretation of these results by the nurse?
- A. The catheter is not positioned correctly and should be removed.
- B. The catheter position increases the risk of ventricular daybisrbr.hcoymth/tmesti as.
- C. The distal tip of the catheter is in the appropriate position.
- D. The physician should be called to advance the catheter into the pulmonary artery.
Correct Answer: C
Rationale: The correct answer is C: The distal tip of the catheter is in the appropriate position.
Rationale:
1. The superior vena cava is a desirable location for a central venous catheter tip placement as it is close to the heart for rapid medication delivery.
2. Catheter tip in the superior vena cava allows for proper venous return and minimizes the risk of complications.
3. The nurse does not need to remove or adjust the catheter if the tip is in the superior vena cava.
4. Advancing the catheter into the pulmonary artery (option D) would be incorrect as it can lead to serious complications.
Incorrect choices:
A: Incorrect because placement in the superior vena cava is acceptable.
B: Incorrect as placement in the superior vena cava does not increase the risk of ventricular dysrhythmias.
D: Incorrect as advancing the catheter into the pulmonary artery is unnecessary and risky.