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Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?
- A. Restrict visitors who irritate the client.
- B. Full rooming-in for the infant and mother.
- C. Supervised and guided visits with infant.
- D. Daily visits with her significant other.
Correct Answer: C
Rationale: The correct answer is C because supervised and guided visits with the infant allow the client to bond with her baby in a safe and structured environment, promoting maternal-infant attachment while ensuring the safety and well-being of both. Restricting visitors who irritate the client (choice A) may increase feelings of isolation and distress. Full rooming-in for the infant and mother (choice B) may overwhelm the client with severe postpartum depression. Daily visits with her significant other (choice D) may not directly address the client's need for bonding with her infant.
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When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.
The nurse is caring for a patient who is mechanically ventilated. The nurse understands that what statement should be considered when determining apapbrirob.pcormia/ttees tn ursing interventions?
- A. Communication with intubated patients is often difficult.
- B. Controlled ventilation is the preferred mode for most p atients.
- C. Patients with chronic obstructive pulmonary disease w ean easily from mechanical ventilation.
- D. Wrist restraints are applied to all patients to avoid self- extubation.
Correct Answer: A
Rationale: The correct answer is A because communication with intubated patients is often challenging due to the presence of an artificial airway, which hinders speech. This understanding is crucial when determining appropriate nursing interventions to ensure effective patient care.
Choice B is incorrect because different patients may require different modes of ventilation based on their specific condition, and controlled ventilation may not always be the preferred mode for all patients.
Choice C is incorrect as patients with chronic obstructive pulmonary disease often have difficulty weaning from mechanical ventilation due to their underlying respiratory condition.
Choice D is incorrect as wrist restraints are not applied to all patients on mechanical ventilation unless absolutely necessary for safety concerns, such as preventing self-extubation.
A nurse who has been recently hired to manage the nursing staff of the ICU is concerned at the lack of evidence-based practice she sees among the staff. Which of the following would be the best step for her to take to promote incorporating evidence into clinical practice?
- A. Only hire nurses certified in critical care nursing.
- B. Leave copies of several different nursing journals in the nurses lounge.
- C. Demonstrate to the staff the best nursing-related search terms to use in Google orYahoo!
- D. Introduce the staff to the PubMed search engine and assign them topics to researchon it.
Correct Answer: D
Rationale: The correct answer is D because introducing the staff to the PubMed search engine and assigning them topics to research on it is the most effective way to promote evidence-based practice. PubMed is a reputable database that contains a vast collection of peer-reviewed articles and research studies, making it a reliable source for evidence. By assigning specific topics, the nurse can ensure that the staff is focusing on relevant and current information, fostering a deeper understanding of evidence-based practice.
Choice A is incorrect because certification in critical care nursing does not guarantee a commitment to evidence-based practice. Choice B is not as effective as it relies on passive exposure to journals rather than active engagement with specific research topics. Choice C is not the best option as using general search terms on search engines like Google or Yahoo may lead to unreliable or outdated information.
Continuous venovenous hemofiltration 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: A
Rationale: The correct answer is A because continuous venovenous hemofiltration (CVVH) primarily removes fluids and solutes through the process of convection. In CVVH, blood flows through a filter where hydrostatic pressure drives plasma water and solutes across a semipermeable membrane. This process mimics the natural filtration that occurs in the kidneys. Choice B is incorrect because CVVH does not specifically target plasma water only but also removes solutes. Choice C is incorrect because CVVH does not involve adding dialysate to remove plasma water and solutes. Choice D is incorrect because while CVVH may involve ultrafiltration and convection, it does not typically include dialysis as a primary mechanism for solute removal.
While caring for a critically ill patient, the nurse knows that fostering patient control over the environment is a method for stress reduction. What nursing intervention gives the patient the most environmental control while still adhering to best practice principles?
- A. Ask the patient whether he or she wants to get out of bed.
- B. Give the patients bath at the same time every day.
- C. Explain painful procedures only after giving pain medication.
- D. Choose menu items for the patient to ensure a balanced diet.
Correct Answer: A
Rationale: Step 1: Asking the patient whether he or she wants to get out of bed allows the patient to make a decision regarding their immediate environment, promoting autonomy and control.
Step 2: This intervention respects the patient's preferences and fosters a sense of dignity and empowerment, reducing stress.
Step 3: Best practice principles in nursing emphasize patient-centered care and promoting patient autonomy.
Summary:
Choice A is correct as it directly involves the patient in decision-making, enhancing their sense of control. Choices B, C, and D do not provide the same level of autonomy and control to the patient, making them less effective in reducing stress and promoting patient well-being.