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The patient’s partner, experiencing anticipatory grieving, tells the nurse, “I don’t see any point in continuing to visit at the bedside, since it’s like I’m not even here.” What is the nurse’s best response to the partner’s statement?
- A. “You’re right, there is no awareness of anything going on now.”
- B. “Unresponsiveness doesn’t mean the sense of hearing is gone and there is a benefit from you being present.”
- C. “I’ll call you if the patient begins responding again.”
- D. “Why don’t you check to see if any other family memb er would like to visit?”
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the partner's feelings while providing information that may help them cope. By stating that unresponsiveness doesn't mean the patient can't hear, the nurse highlights the importance of the partner's presence for emotional support. It encourages the partner to continue visiting, emphasizing their role in providing comfort to the patient.
Choice A is incorrect as it dismisses the partner's feelings and lacks empathy. Choice C is incorrect as it implies the nurse will only involve the partner if the patient responds, neglecting the partner's emotional needs. Choice D is incorrect as it deflects responsibility from addressing the partner's concerns and suggests involving other family members without addressing the partner's feelings directly.
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Family assessment can be challenging and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?
- A. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed .
- B. Develop a standardized reporting form for family infora mbir ab. tc io om n/ te thst a t is incorporated into the patient’s medical record and updated as neede d.
- C. Require that the charge nurse have a detailed list of inf ormation about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues.
- D. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.
Correct Answer: B
Rationale: The correct answer is B because developing a standardized reporting form for family information that is incorporated into the patient's medical record ensures consistency and accuracy in sharing vital details about family structure and dynamics from shift to shift. This method allows all healthcare providers to access the information easily and update it as needed, promoting continuity of care and comprehensive understanding of the family's needs.
Choices A, C, and D are incorrect because:
A: Creating an informal family information sheet may lead to inconsistencies in the information shared among healthcare providers and may not be updated regularly.
C: Requiring only the charge nurse to have detailed information may result in information silos and lack of accessibility for all team members.
D: Discussing family dynamics as part of the change-of-shift report may lead to important details being missed or forgotten, compromising the quality of care provided.
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
- A. Carteolol (Ocupress)
- B. Propranolol hydrochloride (Inderal)
- C. Pindolol (Visken)
- D. Metoprolol tartrate (Lopressor)
Correct Answer: D
Rationale: The correct answer is D, Metoprolol tartrate (Lopressor). Metoprolol is a cardioselective beta-blocker that primarily targets beta-1 receptors in the heart, making it less likely to exacerbate asthma compared to non-selective beta-blockers like Propranolol (choice B) and Pindolol (choice C). Carteolol (choice A) is also a non-selective beta-blocker and can potentially worsen asthma symptoms. Metoprolol's selectivity for beta-1 receptors minimizes bronchoconstriction, making it the safest choice for a client with asthma and high blood pressure.
Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first?
- A. A patient with a red tag.
- B. A patient with a blue tag.
- C. A patient with a black tag.
- D. A patient with a yellow tag.
Correct Answer: A
Rationale: The correct answer is A: A patient with a red tag. In triage, red tags indicate patients with life-threatening injuries who require immediate attention. The nurse must assess this patient first to provide necessary interventions. Patients with blue tags are considered urgent but stable, black tags are deceased or beyond help, and yellow tags are for delayed treatment. Assessing the red-tagged patient first ensures prompt care for those in critical condition.
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
- A. Insert a large-bore orogastric tube.
- B. Assist with the intubation of the patient.
- C. Prepare a 60-mL syringe with saline.
- D. Give the first dose of activated charcoal.
Correct Answer: B
Rationale: The correct answer is B: Assist with the intubation of the patient. In this scenario, the patient is unconscious and has ingested a potentially harmful substance. Intubation is the first priority to maintain the patient's airway and ensure adequate oxygenation. This step is crucial in preventing aspiration of gastric contents and securing the patient's respiratory status. Inserting a large-bore orogastric tube (choice A) is not the priority as airway management takes precedence. Preparing a syringe with saline (choice C) is unnecessary at this stage. Giving the first dose of activated charcoal (choice D) should only be done after securing the airway to prevent aspiration.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
- A. Demonstrates adequate fluid intake and output.
- B. Verbalizes abdominal comfort without pressure.
- C. Drinks 240 mL of fluid five times during the shift.
- D. Voids at least 1000 mL between 7 am and 3 pm.
Correct Answer: C
Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm.
Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount.
Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame.
Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.