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Which intervention about visitation in the critical care unit is true?
- A. The majority of critical care nurses implement restricte d visiting hours to allow the patient to rest.
- B. Children should never be permitted to visit a critically ill family member.
- C. Visitation that is individualized to the needs of patients and family members is ideal.
- D. Visiting hours should always be unrestricted.
Correct Answer: C
Rationale: The correct answer is C because individualized visitation meets the unique needs of patients and family members, promoting holistic care and emotional support. Choice A is incorrect as strictly restricted visiting hours may hinder family involvement in care. Choice B is incorrect as children can provide comfort and support. Choice D is incorrect as unrestricted visiting may disrupt patient rest and care routines.
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The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?
- A. Contact the attending physician immediately to determ ine if CPR should be initiated.
- B. Contact the family immediately to determine if they waabnirtb .CcoPmR/te stot be started.
- C. Give emergency medications but withhold intubation.
- D. Initiate CPR and call a code.
Correct Answer: D
Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.
Which strategy is important to addressing issues associated with the aging workforce? (Select all that apply.)
- A. Allowing nurses to work flexible shift durations
- B. Encouraging older nurses to transfer to an outpatient se tting that is less stressful
- C. Hiring nurse technicians that are available to assist wit h patient care, such as turning the patient
- D. Developing a staffing model that accurately reflects th e unit’s needs.
Correct Answer: A
Rationale: The correct answer is A: Allowing nurses to work flexible shift durations. This strategy is important in addressing issues associated with the aging workforce because it acknowledges the changing needs and preferences of older nurses. By offering flexible shift durations, older nurses can better manage their work-life balance, reduce physical strain, and continue contributing to the workforce effectively.
Choices B, C, and D are incorrect because they do not directly address the specific needs of the aging workforce. Encouraging older nurses to transfer to a less stressful outpatient setting may not align with their career goals. Hiring nurse technicians to assist with patient care may not address the unique experience and expertise of older nurses. Developing a staffing model, while important, does not specifically cater to the needs of aging nurses in terms of flexibility and support.
A normal glomerular filtration rate is
- A. less than 80 mL/min.
- B. 80 to 125 mL/min.
- C. 125 to 180 mL/min.
- D. more than 189 mL/min.
Correct Answer: B
Rationale: The correct answer is B (80 to 125 mL/min) because this range reflects the normal glomerular filtration rate (GFR) in adults. GFR measures the rate at which blood is filtered by the kidneys, typically around 125 mL/min. A GFR below 60 mL/min indicates kidney dysfunction, making option A incorrect. Option C (125 to 180 mL/min) is above the normal range. Option D (more than 189 mL/min) is too high and could indicate hyperfiltration, common in conditions like diabetes. Therefore, choice B is the most appropriate within the normal GFR range.
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
- A. contact the provider and expect a prescription for a normal saline bolus.
- B. wait until the provider makes rounds to report the assessment findings.
- C. continue to evaluate urine output for 2 more hours.
- D. ignore the urine output, as this is most likely postrenal in origin.
Correct Answer: A
Rationale: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia with decreased urine output, low blood pressure, and elevated heart rate. This indicates inadequate perfusion and potential hypovolemic shock. Administering a normal saline bolus will help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (option B) could delay necessary intervention. Continuing to evaluate urine output for 2 more hours (option C) is not appropriate given the patient's current condition. Ignoring the urine output (option D) is dangerous as it could lead to further complications.
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.