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Family assessment can be challenging and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?
- A. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed .
- B. Develop a standardized reporting form for family infora mbir ab. tc io om n/ te thst a t is incorporated into the patient’s medical record and updated as neede d.
- C. Require that the charge nurse have a detailed list of inf ormation about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues.
- D. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.
Correct Answer: B
Rationale: The correct answer is B because developing a standardized reporting form for family information that is incorporated into the patient's medical record ensures consistency and accuracy in sharing vital details about family structure and dynamics from shift to shift. This method allows all healthcare providers to access the information easily and update it as needed, promoting continuity of care and comprehensive understanding of the family's needs.
Choices A, C, and D are incorrect because:
A: Creating an informal family information sheet may lead to inconsistencies in the information shared among healthcare providers and may not be updated regularly.
C: Requiring only the charge nurse to have detailed information may result in information silos and lack of accessibility for all team members.
D: Discussing family dynamics as part of the change-of-shift report may lead to important details being missed or forgotten, compromising the quality of care provided.
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The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?
- A. Increase suctioning to every hour.
- B. Reposition the patient every 1 to 2 hours.
- C. Add additional water to the patient’s enteral feedings.
- D. Instill 5 mL of sterile saline into the ET before suctioning.
Correct Answer: D
Rationale: The correct answer is D: Instill 5 mL of sterile saline into the ET before suctioning. This intervention helps to loosen and mobilize the thick secretions, making them easier to remove during suctioning. It is important to moisten the secretions to prevent mucosal damage and trauma during suctioning.
A: Increasing suctioning frequency can lead to mucosal damage and increased risk of infection.
B: Repositioning helps with ventilation and preventing pressure injuries, but it does not directly address the thick secretions.
C: Adding water to enteral feedings will not directly address the thick secretions in the ET.
In summary, instilling sterile saline into the ET before suctioning is the most effective intervention as it helps to loosen and mobilize thick secretions, making suctioning more effective and reducing the risk of mucosal damage.
The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s living will to the hospital, which identifies the patient’s wiasbhireb.sc orme/gteasrt ding health care. The nurse discusses the contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Pr ofessional Performance?
- A. Acquires and maintains current knowledge of practice
- B. Acts ethically on the behalf of the patient and family
- C. Considers factors related to safe patient care
- D. Uses clinical inquiry and integrates research findings i n practice
Correct Answer: C
Rationale: The correct answer is C: Considers factors related to safe patient care. The scenario involves the nurse discussing the patient's living will with the physician, which is essential for ensuring safe patient care by following the patient's preferences. This aligns with the AACN standard of considering factors related to safe patient care, as the nurse is actively involving all relevant parties in decision-making to provide care that is in line with the patient's wishes.
Explanation of why other choices are incorrect:
A: Acquires and maintains current knowledge of practice - While important, this choice does not directly relate to the scenario where the focus is on safe patient care through communication and collaboration.
B: Acts ethically on behalf of the patient and family - While ethics are important, the scenario is more about following the patient's wishes as outlined in the living will rather than making ethical decisions.
D: Uses clinical inquiry and integrates research findings in practice - While valuable in nursing practice, this choice does not directly apply to the scenario where
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?
- A. The RN increases the FIO2 to 100% before suctioning.
- B. The RN secures a bite block in place using adhesive tape.
- C. The RN asks for assistance to reposition the endotracheal tube.
- D. The RN positions the patient with the head of the bed at 10 degrees.
Correct Answer: D
Rationale: The correct answer is D because positioning the patient with the head of the bed at 10 degrees is incorrect for a patient receiving mechanical ventilation. The optimal position for such patients is to elevate the head of the bed to 30-45 degrees to prevent aspiration and improve oxygenation. Option A is incorrect as increasing FIO2 before suctioning is appropriate to ensure adequate oxygenation. Option B is incorrect as securing a bite block in place using adhesive tape is a standard practice to prevent the patient from biting on the endotracheal tube. Option C is incorrect as asking for assistance to reposition the endotracheal tube shows the RN is aware of the importance of proper placement to ensure effective ventilation.
A nurse in the ICU is responding to a patient who has just gone into cardiac arrest. A moment later, the nurse is notified that another patient has just gone into anaphylactic shock due to a drug allergy. She is conflicted as to what to do, as she is the only nurse available at the moment to tend to both patients. Which component of a healthy work environment is lacking in this scenario?
- A. Effective decision making
- B. Appropriate staffing
- C. Authentic leadership
- D. Meaningful recognition
Correct Answer: B
Rationale: The correct answer is B: Appropriate staffing. In this scenario, the nurse is conflicted because she is the only nurse available to tend to both critical patients. Appropriate staffing ensures that there are enough healthcare professionals to provide timely and effective care to patients in need. In this situation, the lack of adequate staffing is evident as the nurse is overwhelmed and unable to give proper attention to both patients simultaneously. Effective decision making (choice A) can be hindered by inadequate staffing but is not the primary issue here. Authentic leadership (choice C) and meaningful recognition (choice D) are important components of a healthy work environment but are not directly related to the lack of staffing in this scenario.
A young man has just arrived at the ICU from out of town and received news that his girlfriend, who is admitted there, likely only has a few days left to live. Which of the following would be the best approach for the nurse to take in caring for the needs of this young man?
- A. Recommending that he go home and rest
- B. Giving him unrestricted visiting hours with the patient
- C. Suggesting that he meet with the hospital chaplain
- D. Recommending that he ask the doctor to evaluate the patients pain control measures
Correct Answer: C
Rationale: The correct answer is C: Suggesting that he meet with the hospital chaplain. This approach is best as it addresses the young man's emotional and spiritual needs during a difficult time. The chaplain can provide comfort, support, and guidance in coping with his girlfriend's situation. This option focuses on holistic care and acknowledges the importance of emotional well-being.
A: Recommending that he go home and rest is not the best approach as it dismisses the young man's emotional distress.
B: Giving him unrestricted visiting hours with the patient may not be appropriate as it can be overwhelming and may not address his emotional needs effectively.
D: Recommending that he ask the doctor to evaluate the patient's pain control measures is important but does not directly address the young man's emotional needs in this situation.