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The patient’s significant other is terrified by the prospect o f removing life-sustaining treatments from the patient and asks why anyone would do that. What explanation should the nurse provide?
- A. “It is to save you money so you won’t have such a large financial burden.”
- B. “It will preserve limited resources for the hospital so oatbhirebr.c pomat/tieesnt ts may benefit from them.”
- C. “It is to discontinue treatments that are not helping and may be very uncomfortable.”
- D. “We have done all we can for your wife and any more treatment would be futile.”
Correct Answer: C
Rationale: The correct answer is C because it explains that the decision to remove life-sustaining treatments is based on the fact that these treatments are not helping the patient and may actually be causing discomfort. This rationale aligns with the principle of beneficence, which emphasizes doing good and avoiding harm to the patient. It also respects the patient's autonomy by prioritizing their well-being and quality of life.
Choice A is incorrect as it focuses on financial reasons rather than the patient's best interest. Choice B is incorrect because it prioritizes hospital resources over individual patient care. Choice D is incorrect as it lacks clarity and may come across as insensitive to the significant other's concerns.
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A patient in the ICU has recently been diagnosed with diabetes mellitus. Before being discharged, this patient will require detailed instructions on how to manage her diet, how to self-inject insulin, and how to handle future diabetic emergencies. Which nurse competency is most needed in this situation?
- A. Clinical judgment
- B. Advocacy and moral agency
- C. Caring practices
- D. Facilitation of learning
Correct Answer: D
Rationale: The correct answer is D: Facilitation of learning. In this scenario, the nurse needs to effectively educate the patient on managing her diet, insulin injections, and handling emergencies. Facilitation of learning involves assessing the patient's learning needs, providing relevant information, demonstrating skills, and evaluating understanding. This competency is crucial for promoting patient education and empowerment in managing their condition.
A: Clinical judgment involves making decisions based on assessment data, which is important but not the primary focus in this situation.
B: Advocacy and moral agency involve standing up for patients' rights and values, which is important but not as directly relevant to the patient's education needs.
C: Caring practices involve showing empathy and compassion, which are essential but not the main competency required for educational purposes in this case.
A nurse is caring for an elderly man recently admitted to the ICU following a stroke. She assesses his cognitive function using a new cognitive assessment test she learned about in a recent article in a nursing journal. She then brings a cup of water and a straw to the patient because she observes that his lips are dry. Later, she has the patient sit in a wheelchair and takes him to have some blood tests performed. He objects at first, saying that he can walk on his own, but the nurse explains that it is hospital policy to use the wheelchair. That evening, she recognizes signs of an imminent stroke in the patient and immediately pages the physician. Which action taken by the nurse is the best example of evidence-based practice?
- A. Giving the patient a cup of water
- B. Transferring the patient in a wheelchair
- C. Recognizing signs of imminent stroke and paging the physician
- D. Using the cognitive assessment test
Correct Answer: C
Rationale: The correct answer is C: Recognizing signs of an imminent stroke and paging the physician. This action exemplifies evidence-based practice as it involves timely identification of a critical medical condition based on clinical assessment and prompt communication with the physician for further intervention. This aligns with the principles of evidence-based practice, which emphasize the integration of best available evidence with clinical expertise and patient values.
The other choices are incorrect:
A: Giving the patient a cup of water - While providing hydration is important for patient care, it does not demonstrate evidence-based practice in this scenario.
B: Transferring the patient in a wheelchair - Although using a wheelchair may be hospital policy, it does not directly relate to evidence-based practice in this context.
D: Using the cognitive assessment test - While assessing cognitive function is essential, it does not directly address the immediate medical needs of the patient as recognizing signs of an imminent stroke does.
Following surgery for an abdominal aortic aneurysm, the patient’s central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?
- A. Administer IV diuretic medications.
- B. Increase the IV fluid infusion per protocol.
- C. Document the CVP and continue to monitor.
- D. Elevate the head of the patient's bed to 45 degrees.
Correct Answer: B
Rationale: The correct answer is B: Increase the IV fluid infusion per protocol. Low CVP post-abdominal aortic aneurysm surgery could indicate hypovolemia, which requires fluid resuscitation. Increasing IV fluid infusion helps restore intravascular volume, improve tissue perfusion, and prevent hypotension. Administering diuretics (A) would worsen hypovolemia. Documenting (C) is important but not the priority when the patient needs immediate intervention. Elevating the head of the bed (D) may help with venous return but is not the priority over addressing hypovolemia.
What is a strategy for preventing thromboembolism in pat ients at risk who cannot take anticoagulants?
- A. Administration of two aspirin tablets every 4 hours.
- B. Infusion of thrombolytics.
- C. Insertion of a vena cava filter.
- D. Subcutaneous heparin administration every 12 hours.
Correct Answer: C
Rationale: The correct answer is C: Insertion of a vena cava filter. This is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants. The vena cava filter prevents blood clots from traveling to the lungs by trapping them in the inferior vena cava. It is a mechanical device that does not interfere with the body's clotting process.
Explanation of why other choices are incorrect:
A: Administration of two aspirin tablets every 4 hours is not an effective strategy for preventing thromboembolism in high-risk patients. Aspirin is an antiplatelet agent and may not be sufficient for preventing blood clots in these patients.
B: Infusion of thrombolytics is used for breaking down blood clots that have already formed, not for prevention. It is not a suitable option for preventing thromboembolism in at-risk patients.
D: Subcutaneous heparin administration every 12
The nurse cares for an adolescent patient who is dying. The patient’s parents are interested in organ donation and ask the nurse how the decision about brain death is made. Which response by the nurse is most appropriate?
- A. Brain death occurs if a person is flaccid and unresponsive.
- B. If CPR is ineffective in restoring a heartbeat, the brain cannot function.
- C. Brain death has occurred if there is no breathing and certain reflexes are absent.
- D. If respiratory efforts cease and no apical pulse is audible, brain death is present.
Correct Answer: C
Rationale: The correct answer is C: Brain death has occurred if there is no breathing and certain reflexes are absent. Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of breathing and certain reflexes, such as no response to painful stimuli or no pupillary response to light, are key indicators of brain death. This definition is crucial for determining eligibility for organ donation.
Incorrect choices:
A: Brain death occurs if a person is flaccid and unresponsive. Flaccidity and unresponsiveness are not specific criteria for diagnosing brain death.
B: If CPR is ineffective in restoring a heartbeat, the brain cannot function. The absence of a heartbeat alone does not indicate brain death.
D: If respiratory efforts cease and no apical pulse is audible, brain death is present. Respiratory cessation and the absence of pulse are not definitive signs of brain death.