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What is the nurse’s priority intervention when a terminally ill patient reports severe breakthrough pain?
- A. Offer a warm compress to the painful area.
- B. Administer a prescribed PRN opioid analgesic.
- C. Reassess pain level after 2 hours.
- D. Provide distraction techniques to the patient.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed PRN opioid analgesic. This is the priority intervention because severe breakthrough pain requires immediate relief, and opioids are the most effective for managing severe pain in terminally ill patients. Warm compresses (A) may provide some comfort but do not address the underlying pain. Reassessing pain after 2 hours (C) delays necessary relief. Distraction techniques (D) are not appropriate for severe breakthrough pain as they do not directly address the pain itself. Administering the prescribed opioid analgesic promptly is crucial for providing timely and effective pain management in this situation.
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Which statement made by a staff nurse identifying guidelianbeirsb .fcoomr /pteaslt liative care would need corrected?
- A. Basic nursing care is a critical element in palliative car e management.
- B. Common conditions that require palliative management are nausea, agitation, and sleep disturbance.
- C. Palliative care practices are reserved for the dying clie nt.
- D. Palliative care practices relieve symptoms that negativ ely affect the quality of life of a patient.
Correct Answer: C
Rationale: The correct answer is C because palliative care is not just for the dying but also for those with serious illnesses. A: Correct - basic nursing care is essential in palliative care. B: Correct - common symptoms in palliative care include nausea, agitation, and sleep disturbance. D: Correct - palliative care aims to relieve symptoms and improve quality of life. Choice C is incorrect as it wrongly implies palliative care is only for the dying, which is a misconception.
When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?
- A. Zero balance the transducer.
- B. Activate the fast flush system.
- C. Notify the health care provider.
- D. Deflate and reinflate the PA balloon.
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.
Continuous venovenous hemodialysis is used to
- A. remove fluids and solutes through the process of convection.
- B. remove plasma water in cases of volume overload.
- C. remove plasma water and solutes by adding dialysate.
- D. combine ultrafiltration, convection and dialysis
Correct Answer: D
Rationale: The correct answer is D because continuous venovenous hemodialysis combines ultrafiltration, convection, and dialysis techniques. Ultrafiltration removes excess fluid, convection helps in removing solutes, and dialysis involves the diffusion of solutes across a semipermeable membrane. This comprehensive approach ensures effective removal of both fluid and solutes in critically ill patients.
Incorrect Answer Analysis:
A: Removing fluids and solutes through convection alone is not the complete process in continuous venovenous hemodialysis.
B: While volume overload is addressed, continuous venovenous hemodialysis involves more than just removing plasma water.
C: Adding dialysate is not the primary method in continuous venovenous hemodialysis; it involves ultrafiltration, convection, and dialysis techniques.
The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient’s condition is
- A. prerenal.
- B. postrenal.
- C. intrarenal.
- D. not renal related.
Correct Answer: C
Rationale: The correct answer is C: intrarenal. The presence of sediment, crystals, and bacteria in the urinalysis indicates an issue originating within the kidney itself. This suggests a problem like a urinary tract infection or kidney stone causing the severe flank pain. Prerenal and postrenal conditions usually involve issues outside the kidney such as dehydration or urinary tract obstruction, which are not supported by the urinalysis findings. Choice D, not renal related, is incorrect as the symptoms and urinalysis results clearly point towards a renal issue.
The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates undaebrisrbt.acnomd/itnesgt of the purpose of the PAC?
- A. “The catheter will provide multiple sites to give intravenous fluid.”
- B. “The catheter will allow the primary health care provid er to better manage fluid therapy.”
- C. “The catheter tip comes to rest inside my brother’s pul monary artery.”
- D. “The catheter will be in position until the heart has a chance to heal.”
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that the PAC helps in managing fluid therapy effectively. The PAC measures pressures in the heart and lungs, guiding fluid management. Choice A is incorrect as the PAC is not primarily for IV fluid administration. Choice C shows understanding of the catheter placement but not its purpose. Choice D is incorrect as the PAC is not for the heart to heal but to monitor cardiac status.