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The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should
- A. draw a trough level after the next dose of antibiotic.
- B. obtain an order to place the patient on fluid restriction.
- C. assess the patient’s lungs.
- D. insert an indwelling catheter.
Correct Answer: C
Rationale: First, the nurse should assess the patient's lungs to rule out any potential respiratory issues causing fluid retention. This is crucial as the patient has signs of fluid imbalance with decreased output and increased weight. Assessing the lungs can help identify conditions like heart failure or pneumonia that may contribute to these changes. Drawing a trough level (choice A) is not a priority as it doesn't address the immediate concern of fluid imbalance. Placing the patient on fluid restriction (choice B) should only be done after identifying the cause of the imbalance. Inserting an indwelling catheter (choice D) is not necessary at this point as the issue is related to fluid balance, not urinary elimination.
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The nurse recommends that the family of a critically ill patient seek help from the Critical Care Family Assistance Program. What benefit for the family does the nurse anticipate?
- A. Reduction of health care cost
- B. More physical comfort
- C. Multidisciplinary support
- D. Health promotion information
Correct Answer: C
Rationale: The correct answer is C: Multidisciplinary support. The Critical Care Family Assistance Program offers a range of professionals such as social workers, counselors, and financial advisors to provide holistic support to the family. This helps address emotional, financial, and practical needs during a challenging time. Option A is incorrect because the program does not directly reduce healthcare costs. Option B is incorrect as the focus is not solely on physical comfort but on comprehensive support. Option D is incorrect as the primary aim is not health promotion but rather addressing the family's immediate concerns and needs.
A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?
- A. Contact a grief counselor as soon as possible.
- B. Cry along with the patient’s family members.
- C. Leave the home as soon as possible to allow the family to grieve privately.
- D. Consider whether working in hospice is desirable because patient losses are common.
Correct Answer: B
Rationale: The correct answer is B: Cry along with the patient’s family members. This action demonstrates empathy and support for the family's grief, showing that the nurse acknowledges and shares their feelings. It can help the family feel understood and supported during a difficult time. By crying with the family, the nurse can validate their emotions and provide comfort without intruding on their personal space. This approach fosters a sense of connection and trust between the nurse and the family, enhancing the quality of care provided.
Incorrect Choices:
A: Contact a grief counselor as soon as possible - This choice may be premature and could come across as impersonal or distancing in the immediate aftermath of the patient’s death.
C: Leave the home as soon as possible - This choice would be insensitive and could make the family feel abandoned in their time of need.
D: Consider whether working in hospice is desirable because patient losses are common - This choice is inappropriate as it suggests the nurse should reconsider their career choice based on emotional reactions,
A nurse who works in an intermediate care unit has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leade r by staff members and that leadership style is contributing to turnover. The nurse asks to be involved in developing new guidelines to prevent pressure ulcers in the patient populat ion. The nurse manager suggests that the nurse has not yet had enough experience to be on tahbierb p.croemv/teenstt ion task force. This situation and setting is an example of what form of ineffec tive leadership?
- A. Creating a barrier to inter-staff communication.
- B. Supporting a work environment that is unhealthy.
- C. Displaying ineffective decision making.
- D. Demonstrating nursing practice that is not evidence-based.
Correct Answer: C
Rationale: The correct answer is C: Displaying ineffective decision making. In this scenario, the nurse manager's decision to exclude the nurse from participating in developing new guidelines is an example of ineffective decision making. By dismissing the nurse's request based on lack of experience rather than considering their input and involvement, the manager is not utilizing the nurse's expertise and potentially missing out on valuable insights. This decision reflects a lack of inclusivity, collaboration, and respect for the nurse's professional growth and potential contributions. The other choices are not directly applicable in this context as the core issue lies in the manager's decision-making process.
Which of the following nursing activities demonstrates im plementation of the AACN Standards of Professional Performance? (Select all that ap ply.)
- A. Attending a meeting of the local chapter of the Americ an Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught
- B. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family
- C. Participating on the unit’s nurse practice council
- D. Posting an article from Critical Care Nurse on manage ment of venous thromboembolism for your colleagues to read
Correct Answer: C
Rationale: The correct answer is C because participating on the unit's nurse practice council demonstrates adherence to the AACN Standards of Professional Performance, specifically the standard related to quality of practice. By actively engaging in the nurse practice council, the nurse contributes to the development and implementation of policies and procedures that promote quality patient care. This activity also involves collaboration, leadership, and advocacy, which are essential components of professional nursing practice.
The other choices are incorrect because:
A: Attending a meeting and receiving continuing education on sepsis is important for professional development but does not directly align with the AACN Standards of Professional Performance.
B: Collaborating with a pastoral services colleague is essential for holistic patient care but does not specifically address the standards set by the AACN.
D: Posting an article for colleagues to read is beneficial for knowledge sharing but does not directly demonstrate adherence to the AACN Standards of Professional Performance.
represent?
- A. Alveolar oxygen tension.
- B. Oxygen that is chemically combined with hemoglobin .
- C. Oxygen that is physically dissolved in plasma.
- D. Total oxygen consumption.
Correct Answer: B
Rationale: The correct answer is B: Oxygen that is chemically combined with hemoglobin. This is because oxygen primarily travels in the blood by binding to hemoglobin in red blood cells, forming oxyhemoglobin. This process allows for efficient transport of oxygen to tissues throughout the body. Choices A, C, and D are incorrect because:
A: Alveolar oxygen tension refers to the partial pressure of oxygen in the alveoli of the lungs, not the specific form of oxygen in the blood.
C: Oxygen physically dissolved in plasma refers to the small amount of oxygen that is not bound to hemoglobin and is less significant in oxygen transport compared to oxygen bound to hemoglobin.
D: Total oxygen consumption is the overall amount of oxygen utilized by the body, not specifically the form of oxygen bound to hemoglobin for transport.