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The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
- A. Apply a pressure dressing to the insertion site.
- B. Ensure all tubing connections are tightened.
- C. Obtain a portable x-ray to confirm placement.
- D. Restrain the affected extremity for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Obtain a portable x-ray to confirm placement. This is the priority intervention because it ensures the arterial line is correctly positioned, reducing the risk of complications such as dislodgement or improper placement. Applying a pressure dressing (choice A) may be necessary but is not the priority. Ensuring tubing connections are tightened (choice B) is important for preventing leaks but does not address placement. Restraining the affected extremity (choice D) is unnecessary and can lead to complications. The x-ray confirms correct placement, ensuring accurate monitoring and treatment.
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The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
- A. Withhold the medication and contact the healthcare provider.
- B. Give the medication dosage as scheduled.
- C. Assess respiratory rate for one minute next.
- D. Wait 30 minutes and give half of the dosage of medication.
Correct Answer: A
Rationale: The correct answer is A. Infants typically have higher resting heart rates than adults, so a pulse rate of 89 beats/minute for an infant may indicate bradycardia. Digoxin can further lower the heart rate, leading to potential adverse effects like arrhythmias. Therefore, withholding the medication and contacting the healthcare provider is crucial to ensure the safety of the infant.
Choice B is incorrect because administering digoxin without addressing the elevated pulse rate can be dangerous. Choice C is incorrect as assessing respiratory rate does not address the immediate concern of the elevated pulse rate. Choice D is also incorrect as waiting and giving half of the dosage may further exacerbate the situation.
What should a designated healthcare surrogate base healthcare decisions on?
- A. Personal beliefs and values
- B. Recommendations of family members and friends
- C. Recommendations of the physician and healthcare team
- D. Wishes previously expressed by the patient
Correct Answer: C
Rationale: The correct answer is C because the healthcare surrogate should base decisions on recommendations of the physician and healthcare team who have the expertise to provide medical advice. They are best positioned to understand the patient's condition and treatment options. Personal beliefs (A) may not align with medical best practices. Family and friends' recommendations (B) may not be informed by medical knowledge. Wishes previously expressed by the patient (D) are important but may need to be interpreted in the context of the current medical situation, which healthcare professionals can provide.
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.
Anxiety differs from pain in that way? (Select all that app ly.)
- A. Anxiety is confined to neurological processes in the brain.
- B. Anxiety is linked to reward and punishment centers in the limbic system.
- C. Anxiety is subjective; pain is not.
- D. Anxiety produces no actual tissue injury.
Correct Answer: B
Rationale: The correct answer is B because anxiety is indeed linked to reward and punishment centers in the limbic system, specifically involving the amygdala and prefrontal cortex. This connection influences emotional responses and behaviors related to anxiety. Choices A, C, and D are incorrect because anxiety involves both neurological and psychological processes beyond the brain, is highly subjective like pain, and can lead to physical symptoms without actual tissue injury.
The client has been in the CCU for several weeks and has been very unstable. One family member stays at the bedside constantly and even naps in a bedside chair. The nurse understands that the family member is exhibiting which family member response to critical illness?
- A. Exhibiting extreme distrust of the health care team
- B. Seeking evidence for future legal or punitive action
- C. Trying to maintain a level of control over the situation
- D. Experiencing extreme fatigue from constant stress
Correct Answer: C
Rationale: The correct answer is C: Trying to maintain a level of control over the situation. The family member staying at the bedside constantly and even napping there is likely trying to cope with the stressful situation by maintaining a sense of control and connection to the patient. This behavior can be a way for the family member to feel more involved and helpful during a time of uncertainty and powerlessness. Choices A and B involve negative assumptions about the family member's intentions without evidence. Choice D may be a result of the family member's actions but does not address the underlying motivation for their behavior.