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A family member approaches the nurse caring for their gra vely ill son and states, “We want to donate our son’s organs.” What is the best action by the nu rse?
- A. Arrange a multidisciplinary meeting with physicians.
- B. Consult the hospital’s ethics committee for a ruling.
- C. Notify the organ procurement organization (OPO).
- D. Obtain family consent to withdraw life support.
Correct Answer: C
Rationale: The correct answer is C: Notify the organ procurement organization (OPO). This is the best action because the OPO is responsible for coordinating organ donation and transplantation. By involving the OPO, the nurse ensures that the donation process is handled appropriately and ethically.
Choice A: Arranging a multidisciplinary meeting with physicians may be necessary but should not be the first step in this situation.
Choice B: Consulting the hospital’s ethics committee may be helpful, but the immediate priority is to involve the OPO to facilitate organ donation.
Choice D: Obtaining family consent to withdraw life support is not the nurse’s role in this situation. The focus should be on organ donation to honor the family's wishes.
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The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)
- A. Airway clearance therapies
- B. Antibiotic therapy
- C. Nutritional support
- D. Tracheostomy
Correct Answer: A
Rationale: The correct answer is A: Airway clearance therapies. In cystic fibrosis (CF), mucus buildup in the lungs can lead to infections and breathing difficulties. Airway clearance therapies help loosen and clear this mucus, improving lung function. Antibiotic therapy (B) is used to treat infections but is not specific to CF treatment. Nutritional support (C) is crucial in CF due to malabsorption, but it is not the primary treatment. Tracheostomy (D) is a surgical procedure to create an airway bypassing the upper respiratory tract and is not a standard treatment for CF.
The nurse is caring for a patient diagnosed with hyperactivaebi rdb.ecloimri/tuemst . The nurse focuses interventions toward which priority need?
- A. Comfort
- B. Nourishment
- C. Safety
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.
Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research?
- A. Clinical practice guidelines
- B. Computerized physician order entry
- C. Consulting with advanced practice nurses
- D. Implementing Joint Commission National Patient Safe ty Goals
Correct Answer: A
Rationale: The correct answer is A: Clinical practice guidelines. Clinical practice guidelines are evidence-based recommendations that assist nurses in providing appropriate care based on research. They outline best practices for specific patient populations or conditions, helping nurses make informed decisions.
Summary:
- B: Computerized physician order entry: While it may improve accuracy and efficiency, it does not specifically ensure care based on research.
- C: Consulting with advanced practice nurses: While collaboration is valuable, it does not guarantee care based on research.
- D: Implementing Joint Commission National Patient Safety Goals: Important for patient safety, but not directly related to ensuring care based on research.
Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict?
- A. A 21-year-old college student of divorced parents hosp italized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter’s b oyfriend for causing the accident.
- B. A 36-year-old male admitted for a ruptured cerebral an eurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have written advance directives. His parents aarbriribv.ceo mfr/otemst out-of-state and are asked to make decisions about his health care. He h as not seen them in over a year.
- C. A 58-year-old male admitted for coronary artery bypas s surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his healthca re proxy in a written advance directive.
- D. A 78-year-old female admitted with gastrointestinal blaebeirdbi.cnogm./ tHeset r hemoglobin is decreasing to a critical level. She is a Jehovah’s Witness and refuses the treatment of a blood transfusion. She is capable of making her ow n decisions and has a clearly written advance directive declining any transfu sions. Her son is upset with her and tells her she is “committing suicide.”
Correct Answer: D
Rationale: The correct answer is D because it involves a conflict between the patient's autonomy and her son's beliefs. The patient, a Jehovah's Witness, has clearly stated her refusal of a blood transfusion in her advance directive, which aligns with her religious beliefs. Her son's disagreement with her decision creates a significant ethical dilemma and conflict. This scenario highlights the clash between respecting the patient's autonomy and the son's concerns for her well-being.
Choice A is less likely to result in the greatest conflict as both parents have similar values and are amicable, with the conflict being directed towards the daughter's boyfriend.
Choice B involves a conflict between the patient's girlfriend and parents, but the patient's lack of advance directives and estranged relationship with his parents do not present as significant a conflict as in the correct answer.
Choice C involves a designated healthcare proxy and a committed relationship, which are less likely to result in a conflict as compared to the clash of beliefs and autonomy seen in Choice D.
Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter?
- A. Determine if the cardiac troponin level is elevated.
- B. Auscultate heart and breath sounds during insertion.
- C. Place the patient on NPO status before the procedure.
- D. Attach cardiac monitoring leads before the procedure.
Correct Answer: D
Rationale: The correct answer is D: Attach cardiac monitoring leads before the procedure. This is essential to monitor the patient's cardiac rhythm and detect any abnormalities during catheter insertion. Cardiac monitoring leads provide real-time information on the patient's heart rate and rhythm, allowing the nurse to promptly address any complications.
A: Determining if the cardiac troponin level is elevated is not directly related to assisting with pulmonary artery catheter insertion.
B: Auscultating heart and breath sounds during insertion is important but does not take precedence over attaching cardiac monitoring leads.
C: Placing the patient on NPO status before the procedure may be necessary for other procedures, but it is not specifically required for assisting with pulmonary artery catheter insertion.