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The primary health care provider writes an order to discon tinue a patient’s left radial arterial line. When discontinuing the patient’s invasive line, what is the priority nursing action?
- A. Apply an air occlusion dressing to insertion site.
- B. Apply pressure to the insertion site for 5 minutes.
- C. Elevate the affected limb on pillows for 24 hours.
- D. Keep the patient’s wrist in a neutral position.
Correct Answer: B
Rationale: The correct answer is B: Apply pressure to the insertion site for 5 minutes. This is the priority nursing action because it helps prevent bleeding and hematoma formation after removing the arterial line. Applying pressure for 5 minutes allows for adequate hemostasis.
A: Applying an air occlusion dressing to the insertion site is not the priority action. It does not address the immediate need to control bleeding.
C: Elevating the affected limb on pillows for 24 hours is not necessary and does not address the immediate need for hemostasis.
D: Keeping the patient's wrist in a neutral position is not the priority action when discontinuing an arterial line. It does not address the need for hemostasis and preventing bleeding.
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Which of the following is a National Patient Safety Goal? a(bSirebl.ceocmt /taelslt that apply.)
- A. Accurately identify patients.
- B. Eliminate use of patient restraints.
- C. Reconcile medications across the continuum of care.
- D. Reduce risks of healthcare-acquired infection.
Correct Answer: A
Rationale: Rationale: Accurately identifying patients is a National Patient Safety Goal to prevent errors in patient care. Proper patient identification ensures correct treatments and medications are given, reducing harm. Restraint elimination, medication reconciliation, and infection reduction are important goals but not specific National Patient Safety Goals. Accurate patient identification directly addresses patient safety concerns.
Which statement is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)
- A. Tooth brushing is performed every 2 hours for the greatest effect.
- B. Implementing a comprehensive oral care program is an intervention for preventing WWW .THENURSINGMASTERY.COM VAP.
- C. Oral care protocols should include oral suctioning and brushing teeth.
- D. Protocols that include chlorhexidine gluconate have beaebnirb e.cfofme/ctetsivt e in preventing VAP.
Correct Answer: B
Rationale: The correct answer is B. Implementing a comprehensive oral care program is an intervention for preventing VAP. This statement is true because proper oral care, including brushing teeth, oral suctioning, and using chlorhexidine gluconate, has been shown to reduce the risk of VAP by decreasing the colonization of pathogenic bacteria in the oral cavity. Regular oral care helps maintain oral hygiene and reduce the risk of aspiration of bacteria into the lungs, which is a common cause of VAP.
Incorrect Answer Analysis:
A: Tooth brushing every 2 hours may be excessive and could potentially cause harm to the oral mucosa, leading to increased risk of infection.
C: While oral suctioning and brushing teeth are important components of oral care, the statement is not comprehensive enough to address the full range of interventions needed to prevent VAP.
D: While chlorhexidine gluconate can be effective in preventing VAP, the statement implies that it is the only effective intervention, which is not true.
The patient’s serum creatinine level is 0.7 mg/dL. The expected BUN level should be
- A. 1 to 2 mg/dL.
- B. 7 to 14 mg/dL.
- C. 10 to 20 mg/dL.
- D. 20 to 30 mg/dL.
Correct Answer: C
Rationale: The correct answer is C (10 to 20 mg/dL). The normal BUN-to-creatinine ratio is approximately 10:1. With a serum creatinine level of 0.7 mg/dL, the expected BUN level should be around 7 to 14 mg/dL. Therefore, choice C (10 to 20 mg/dL) falls within this expected range. Choices A, B, and D are incorrect as they do not align with the typical BUN-to-creatinine ratio and would indicate abnormal kidney function.
Both the electroencephalogram (EEG) monitor and the Bis pectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to ass ess patient sedation levels in critically ill patients. Why are the BIS and PSI monitors simpler to use?
- A. They are only be used on heavily sedated patients.
- B. They can only be used on pediatric patients.
- C. They provide raw EEG data and a numeric value.
- D. They require only five leads.
Correct Answer: C
Rationale: The correct answer is C because BIS and PSI monitors provide both raw EEG data and a numeric value, simplifying the interpretation of patient sedation levels. Raw EEG data offers detailed information on brain activity, while the numeric value allows for quick assessment. This simplifies the monitoring process compared to interpreting raw EEG data alone.
Choice A is incorrect as BIS and PSI monitors are not restricted to heavily sedated patients. Choice B is incorrect as they are not limited to pediatric patients. Choice D is incorrect as the number of leads required does not determine the simplicity of use; it is the data interpretation that matters.
The AACN Standards for Acute and Critical Care Nursing Practice uses what framework to guide critical care nursing practice?
- A. Evidence-based practice
- B. Healthy work environment
- C. National Patient Safety Goals
- D. Nursing process
Correct Answer: A
Rationale: The correct answer is A: Evidence-based practice. The AACN Standards for Acute and Critical Care Nursing Practice emphasize the use of evidence-based practice to guide critical care nursing. This framework ensures that nursing interventions are based on the best available evidence, leading to improved patient outcomes. Healthy work environment (B) and National Patient Safety Goals (C) are important but not specific frameworks for critical care nursing. The nursing process (D) is a systematic approach to delivering patient care but is not the primary guiding framework in critical care nursing practice.