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A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
- A. Fit the client with a respirator mask.
- B. Assign the client to a negative air-flow room.
- C. Don a clean gown for client care.
- D. Place an isolation cart in the hallway.
Correct Answer: B
Rationale: The correct answer is B: Assign the client to a negative air-flow room. This is crucial to prevent the spread of TB to other patients and healthcare workers. Negative air-flow rooms help contain airborne pathogens. Option A is not sufficient as it only protects the client, not others. Option C is important for infection control but not the priority in this situation. Option D is not as effective as placing the client in a negative air-flow room. Overall, option B is the best choice to ensure the safety of everyone in the unit.
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Which of the following professional organizations best supports critical care nursing practice?
- A. American Association of Critical-Care Nurses
- B. American Heart Association
- C. American Nurses Association
- D. Society of Critical Care Medicine
Correct Answer: A
Rationale: The correct answer is A: American Association of Critical-Care Nurses (AACN). This organization focuses exclusively on critical care nursing, offering specialized education, resources, and certifications for critical care nurses. AACN advocates for high standards of care in critical care settings. The other choices do not specifically cater to critical care nursing practice. The American Heart Association focuses on cardiovascular health, the American Nurses Association is a general nursing organization, and the Society of Critical Care Medicine is more physician-centric. Therefore, A is the best choice for supporting critical care nursing practice.
Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.)
- A. Inability to communicate
- B. Invasive procedures
- C. Monitoring devices
- D. Preexisting conditions
Correct Answer: A
Rationale: The correct answer is A: Inability to communicate. Critically ill patients often experience pain and anxiety due to their inability to effectively communicate their needs and discomfort. This can lead to unaddressed pain and increased anxiety levels. Choices B, C, and D are incorrect because while invasive procedures, monitoring devices, and preexisting conditions can contribute to pain and anxiety in critically ill patients, they are not factors that directly predispose patients to these issues. It is the lack of communication that significantly hinders the ability to address and manage pain and anxiety effectively in these patients.
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best inter pretation of these results by the nurse?
- A. The catheter is not positioned correctly and should be removed.
- B. The catheter position increases the risk of ventricular daybisrbr.hcoymth/tmesti as.
- C. The distal tip of the catheter is in the appropriate position.
- D. The physician should be called to advance the catheter into the pulmonary artery.
Correct Answer: C
Rationale: The correct answer is C: The distal tip of the catheter is in the appropriate position.
Rationale:
1. The superior vena cava is a desirable location for a central venous catheter tip placement as it is close to the heart for rapid medication delivery.
2. Catheter tip in the superior vena cava allows for proper venous return and minimizes the risk of complications.
3. The nurse does not need to remove or adjust the catheter if the tip is in the superior vena cava.
4. Advancing the catheter into the pulmonary artery (option D) would be incorrect as it can lead to serious complications.
Incorrect choices:
A: Incorrect because placement in the superior vena cava is acceptable.
B: Incorrect as placement in the superior vena cava does not increase the risk of ventricular dysrhythmias.
D: Incorrect as advancing the catheter into the pulmonary artery is unnecessary and risky.
Family members have a need for information. Which intervention best assists in meeting this need?
- A. Handing family members a pamphlet that explains all of the critical care equipment
- B. Providing a daily update of the patient’s progress and f acilitating communication with the intensivist
- C. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist
- D. Writing down a list of all new medications and doses a nd giving the list to family members during visitation
Correct Answer: B
Rationale: The correct answer is B because providing a daily update of the patient's progress and facilitating communication with the intensivist directly addresses the family members' need for information in a timely and personalized manner. This intervention ensures that the family is kept informed about the patient's condition and treatment plan, fostering transparency and trust. It also allows for any questions or concerns to be addressed promptly, aiding in the family's understanding and involvement in the patient's care.
Now, let's summarize why the other choices are incorrect:
A: Handing out a pamphlet may provide information, but it lacks the personalized touch and real-time updates that are crucial for meeting the family's need for information.
C: Restricting information and only allowing family members to be present at specific times may create frustration and hinder communication, not effectively meeting their information needs.
D: Providing a list of medications is helpful, but it does not offer a comprehensive update on the patient's progress or facilitate direct communication with the medical team, which are
Which statement reflects adherence to current recommendations concerning open visitation policies?
- A. Allowing animals on the unit; however, these can only be “therapy” animals through the hospital’s pet therapy program.
- B. Allowing family visitation throughout the day except a t change of shift and during rounds.
- C. Determining, in collaboration with the patient and famaiblyirb, .cwomho/te csta n visit and when.
- D. Permitting open visitation by adults 18 years of age and older; limit visits of children to 1 hour.
Correct Answer: C
Rationale: The correct answer is C because it reflects patient-centered care by involving patients and families in decision-making. Collaborating with them on visitation preferences promotes a supportive environment. Choice A restricts animal visitation, not addressing human visitors. Choice B limits visitation during specific times, not individualized. Choice D imposes restrictions based on age, not on patient/family preferences. Therefore, Choice C is the most aligned with current recommendations for open visitation policies.