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To prevent any unwanted resuscitation after life-sustaininga btirrbe.acotmm/teenstt s have been withdrawn, the nurse should ensure that what intervention has been im plemented?
- A. Do-not-resuscitate (DNR) orders are written before dis continuation of the treatments.
- B. The family is not allowed to visit until the death occur s.
- C. DNR orders are written as soon as possible after the di scontinuation of the treatments.
- D. The change-of-shift report includes the information thaatb irtbh.ceo pma/tetiset nt is not to be resuscitated.
Correct Answer: A
Rationale: The correct answer is A because writing DNR orders before discontinuation of life-sustaining treatments ensures clear communication and legal documentation of the patient's wishes. Choice B is incorrect as family support is essential in end-of-life care. Choice C is incorrect as DNR orders should be established before withdrawing treatment. Choice D is incorrect as the DNR order should be in place before shift change for immediate implementation if needed.
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The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
- A. A patient with no pedal pulses.
- B. A patient with an open femur fracture.
- C. A patient with bleeding facial lacerations.
- D. A patient with paradoxical chest movements.
Correct Answer: D
Rationale: The correct answer is D: A patient with paradoxical chest movements. This indicates flail chest, a life-threatening condition where a segment of the chest wall moves independently from the rest.
1. Flail chest can lead to respiratory compromise and potential respiratory failure.
2. Immediate intervention is needed to stabilize the chest wall and support breathing.
3. Without prompt treatment, the patient can develop hypoxia and potentially progress to cardiac arrest.
Summary:
- Choice A: No pedal pulses may indicate vascular compromise but does not pose an immediate threat to life.
- Choice B: Open femur fracture requires urgent treatment but does not have the same immediate life-threatening implications as flail chest.
- Choice C: Bleeding facial lacerations can be managed after addressing more critical injuries like flail chest.
What is the main purpose of certification for critical care n ursing?
- A. To assure the consumer that critical nurses will not make a mistake.
- B. To help prepare the critical care nurse for graduate sch ool.
- C. To assist in promoting magnet status for a facility.
- D. To validate a nurse’s knowledge of critical care nursing
Correct Answer: D
Rationale: The correct answer is D: To validate a nurse’s knowledge of critical care nursing. Certification in critical care nursing validates a nurse's expertise and knowledge in this specialized area of nursing. It demonstrates that the nurse has met certain standards and competencies in critical care practice. This certification ensures that the nurse is well-equipped to provide high-quality care to critically ill patients.
A: To assure the consumer that critical nurses will not make a mistake - This choice is incorrect because certification does not guarantee that nurses will not make mistakes. It focuses on validating knowledge and skills rather than infallibility.
B: To help prepare the critical care nurse for graduate school - This choice is incorrect as certification is more focused on practice readiness rather than academic preparation.
C: To assist in promoting magnet status for a facility - This choice is incorrect as magnet status relates more to the overall excellence and quality of nursing care in a facility, not individual certification.
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.
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?
- A. Hypothyroidism.
- B. Thyroid cyst.
- C. Thyroid cancer.
- D. Hyperthyroidism.
Correct Answer: D
Rationale: The presence of a bruit over the thyroid indicates increased blood flow, characteristic of hyperthyroidism. This excess blood flow is due to the hypermetabolic state in hyperthyroidism, leading to turbulent blood flow and the audible bruit. A bruit is not typically associated with hypothyroidism, thyroid cysts, or thyroid cancer, as these conditions do not cause increased blood flow. Therefore, the correct interpretation is hyperthyroidism.
A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?
- A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
- B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
- C. Encourage the family to request that the physician evaluate the patients pain control.
- D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C
Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.
Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.