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Upon entering the room of a patient with a right radial arte rial line, the nurse assesses the waveform to be slightly dampened and notices blood to bea bbirabc.ckoemd/te ustp into the pressure tubing. What is the best action by the nurse?
- A. Check the inflation volume of the flush system pressur e bag.
- B. Disconnect the flush system from the arterial line catheter.
- C. Zero reference the transducer system at the phlebostati c axis. WWWWWW ..TTHHEENNUURRSSIINNGGMMAASSTTEERRYY..CCOOMM
- D. Reduce the number of stopcocks in the flush system tubing.
Correct Answer: B
Rationale: The correct answer is B: Disconnect the flush system from the arterial line catheter. This action is necessary to prevent air from entering the patient's bloodstream, which can lead to air embolism. By disconnecting the flush system, the nurse stops the flow of air and ensures patient safety. Checking the inflation volume of the pressurized bag (A) is not the immediate concern in this situation. Zero referencing the transducer system (C) is unrelated to the issue of air entering the arterial line. Reducing the number of stopcocks in the flush system tubing (D) does not address the immediate risk of air embolism.
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The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)
- A. Agitation
- B. Apathy
- C. Biting
- D. Hitting
Correct Answer: A
Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.
What nonpharmacological approaches to pain and/or anxie ty may best meet the needs of critically ill patients? (Select all that apply.)
- A. Anaerobic exercise
- B. Art therapy
- C. Guided imagery
- D. Music therapy
Correct Answer: B
Rationale: The correct answer is B: Art therapy. Art therapy can help critically ill patients express emotions, reduce anxiety, and cope with pain in a nonverbal way. It provides a creative outlet for self-expression and can improve overall well-being. Anaerobic exercise (A) may not be suitable for critically ill patients due to physical limitations. Guided imagery (C) may not be effective for all patients and requires a certain level of cognitive ability. Music therapy (D) can be beneficial, but art therapy is specifically known for its effectiveness in addressing emotional and psychological needs in critically ill patients.
The family of your critically ill patient tells you that they h ave not spoken with the physician in over 24 hours and they have some questions that they w ant clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which com petency of critical care nursing does this represent?
- A. Advocacy and moral agency in solving ethical issues
- B. Clinical judgment and clinical reasoning skills
- C. Collaboration with patients, families, and team membe rs
- D. Facilitation of learning for patients, families, and team members
Correct Answer: C
Rationale: The correct answer is C: Collaboration with patients, families, and team members. By addressing the family's concern about lack of communication with the physician and arranging a meeting between the intensivist and the family, the nurse is demonstrating collaboration skills in facilitating communication and ensuring the family's questions are addressed. This competency emphasizes the importance of working together with patients, families, and the healthcare team to provide optimal care.
Incorrect choices:
A: Advocacy and moral agency in solving ethical issues - While advocacy is important in nursing, in this scenario, the focus is on communication and collaboration rather than ethical issues.
B: Clinical judgment and clinical reasoning skills - Although these skills are crucial in critical care nursing, the situation described does not primarily involve clinical judgment but rather communication and collaboration.
D: Facilitation of learning for patients, families, and team members - While patient education is important, the main focus of the scenario is on addressing the family's concerns and facilitating communication, rather than educational aspects.
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.
Warning signs that can assist the critical care nurse in reco gnizing that an ethical dilemma may exist include which of the following? (Select all that apply.)
- A. Family members are confused about what is happening to the patient.
- B. Family members are in conflict as to the best treatmen t options. They disagree with each other and cannot come to consensus.
- C. The family asks that the patient not be told of treatmenatb iprbl.aconms./t est
- D. The patient’s condition has changed dramatically for the worse and is not responding to conventional treatment.
Correct Answer: A
Rationale: The correct answer is A because when family members are confused about the patient's condition or treatment, it can indicate a lack of communication or understanding, leading to a potential ethical dilemma. This confusion may result in conflicting views on what is best for the patient, potentially leading to disagreements and ethical conflicts.
Choice B is incorrect because although family conflict can lead to ethical dilemmas, it is not a direct warning sign that an ethical dilemma exists.
Choice C is incorrect because the family asking not to inform the patient about treatment is more related to communication preferences rather than a clear indication of an ethical dilemma.
Choice D is incorrect because a deteriorating patient condition, while concerning, does not directly signal an ethical dilemma unless there are specific ethical considerations involved in the treatment decisions.