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What is the most important nursing intervention for patien ts who receive neuromuscular blocking agents?
- A. Administer sedatives in conjunction with the neuromu as bc iu rbl .a cor m b /tl eo sc t king agents.
- B. Assess neurological status every 30 minutes.
- C. Avoid interaction with the patient, because he or she won’t be able to hear.
- D. Restrain the patient to avoid self-extubation.
Correct Answer: B
Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention.
A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise.
C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care.
D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function.
Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.
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A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The nurse asks the patient, Can you tell me what you are thinking now? The patient responds, I cant take this pain any more! I feel like Im about to die. What would be the best response for the nurse to give to the patient, considering that the patient is already receiving the maximum amount pain medication that is safe?
- A. Try to get rid of those negative thoughtsthey only make it worse.
- B. Try thinking instead, This pain will go away; I can overcome it.
- C. Your pain medication is already at the highest possible dose.
- D. Would you like me to raise the head of your bed?
Correct Answer: C
Rationale: The correct response is C: Your pain medication is already at the highest possible dose. This response acknowledges the patient's pain and reassures them that they are already receiving the maximum safe amount of pain medication. By stating this, the nurse is validating the patient's experience and showing empathy. It is important for the nurse to communicate clearly about the medication to manage the patient's expectations.
Choice A is incorrect as it dismisses the patient's pain and can come across as insensitive. Choice B may be well-intentioned but does not address the immediate concern of the patient's pain. Choice D is irrelevant to the patient's statement about pain and does not offer any immediate support or reassurance regarding the pain management.
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.
The assessment of pain and anxiety is a continuous proces s. When critically ill patients exhibit signs of anxiety, what is the nurse’s first priority?
- A. To administer antianxiety medications as ordered
- B. To administer pain medication as ordered
- C. To identify and treat the underlying cause
- D. To reassess the patient hourly to determine whether symptoms resolve on their own
Correct Answer: C
Rationale: The correct answer is C: To identify and treat the underlying cause. The first priority of the nurse when critically ill patients exhibit signs of anxiety is to determine the root cause of the anxiety. By identifying and addressing the underlying cause, the nurse can effectively manage the patient's anxiety and prevent further complications. Administering medications without understanding the cause can mask the symptoms and lead to ineffective treatment. Reassessing the patient hourly may not address the root cause and could delay appropriate intervention. Pain medication may not be necessary if the anxiety is not related to pain. Treating the underlying cause ensures holistic and effective care for the patient.
The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings?
- A. Explain procedures to the patient and family.
- B. Ask the patient to share his or her internal dialogue.
- C. Encourage the patient to nap before visiting hours.
- D. Ensure that the patient has adequate pain control.
Correct Answer: B
Rationale: The correct answer is B because asking the patient to share his or her internal dialogue can provide direct insight into the patient's thoughts and feelings, allowing the nurse to address specific anxieties. This approach promotes open communication and understanding. Choice A focuses on providing information but may not directly address the patient's feelings. Choice C is unrelated to addressing the patient's anxiety. Choice D addresses pain control, which is important but not directly related to exploring the patient's emotions. Therefore, option B is the most effective strategy for gaining insight into the patient's feelings in this scenario.
Which nursing actions are most important for a patient witahb irab .croigmh/tte srta dial arterial line? (Select all that apply.)
- A. Checking the circulation to the right hand every 2 hour s
- B. Maintaining a pressurized flush solution to the arterial line setup
- C. Monitoring the waveform on the monitor for dampenin g
- D. Restraining all four extremities with soft limb restraint s
Correct Answer: A
Rationale: Step 1: Checking circulation to the right hand is crucial for assessing perfusion and detecting potential complications.
Step 2: Arterial line placement can compromise blood flow, leading to ischemia if circulation is impaired.
Step 3: Monitoring circulation every 2 hours allows for early detection of issues and prompt intervention.
Step 4: This action ensures patient safety and prevents complications.
Summary:
- Choice B is incorrect as pressurized flush solution can increase the risk of complications.
- Choice C is incorrect as monitoring the waveform is important but not the most critical action.
- Choice D is incorrect as limb restraints can impede circulation and are unnecessary in this scenario.