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Which nursing interventions would best support the family of a critically ill patient?
- A. Encouraging family members to stay all night in case t he patient needs them.
- B. Giving a condition update each morning and whenever changes occur.
- C. Limiting visitation from children into the critical care u nit.
- D. Providing beverages and snacks in the waiting room.
Correct Answer: B
Rationale: The correct answer is B because giving regular condition updates promotes transparency and communication, reducing anxiety for the family. This intervention helps them stay informed and involved in the patient's care. Choice A may lead to caregiver fatigue and is not sustainable. Choice C limits family support and may increase stress. Choice D focuses on comfort but does not address the family's need for information.
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Which of the following is (are) official journal(s) of the A merican Association of Critical-Care Nurses? (Select all that apply.)
- A. American Journal of Critical Care
- B. Critical Care Clinics of North America
- C. Critical Care Nurse
- D. Critical Care Nursing Quarterly
Correct Answer: A
Rationale: Step-by-step rationale:
1. The American Association of Critical-Care Nurses (AACN) publishes the American Journal of Critical Care (AJCC).
2. The AJCC is a peer-reviewed journal that covers critical care nursing practice, research, and education.
3. The content in AJCC aligns with AACN's mission and standards for critical care nursing.
4. Hence, AJCC is an official journal of AACN.
Summary of other choices:
- B: Critical Care Clinics of North America - Not an official journal of AACN.
- C: Critical Care Nurse - Not an official journal of AACN.
- D: Critical Care Nursing Quarterly - Not an official journal of AACN.
A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient?
- A. Insist that only a female doctor be assigned to this patient.
- B. Ensure that no pork products are included in the patients diet.
- C. Ensure that direct eye contact is not made with the patients husband.
- D. Ask the patients husband what religious and cultural preferences should be considered in the patients care.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates respect for the patient's autonomy and individual preferences. By asking the patient's husband about religious and cultural preferences, the nurse acknowledges the importance of involving the family in decision-making and shows sensitivity to the patient's beliefs. This approach promotes cultural competence and patient-centered care.
Choice A is incorrect because insisting on a female doctor may not align with the patient's preferences and may limit the available medical staff. Choice B is also incorrect as dietary restrictions are not necessarily the most pressing issue in this scenario. Choice C is incorrect as it assumes a cultural practice without verifying the patient's specific preferences and may not be necessary or appropriate in this context.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. Has the client experienced constipation recently?
- B. Did the client miss any doses of the medication?
- C. How long has the client been taking the medication?
- D. Does the client use any tobacco products?
Correct Answer: C
Rationale: The correct answer is C. Assessing how long the client has been taking clonidine is crucial as drowsiness is a common side effect that typically improves over time as the body adjusts to the medication. This information helps determine if the drowsiness is a temporary side effect or a more concerning issue.
Choice A (constipation) is not directly related to drowsiness as a side effect of clonidine. Choice B (missed doses) may contribute to drowsiness but is not the primary assessment priority. Choice D (tobacco use) is not directly related to clonidine-induced drowsiness.
The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications?
- A. Give around-the-clock routine administration of analgesics.
- B. Provide PRN doses of medication whenever the patient requests.
- C. Offer enough pain medication to keep the patient sedated.
- D. Suggest analgesic doses that provide pain control without decreasing respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Give around-the-clock routine administration of analgesics. This is the best approach for managing continuous and severe pain in a terminally ill patient. By providing scheduled doses of opioid pain medications, the nurse ensures a consistent level of pain relief, preventing peaks and troughs in pain control. This approach also helps in preventing the patient from experiencing unnecessary suffering.
Choice B (PRN doses) may lead to inadequate pain control as the patient may wait too long before requesting medication. Choice C (keeping the patient sedated) is not appropriate as the goal is pain management, not sedation. Choice D (balancing pain control and respiratory rate) is important, but the priority should be on effectively managing the pain first.
Which interventions may be included during “terminal we aning”? (Select all that apply.)
- A. Complete extubation following ventilator withdrawal
- B. Discontinuation of artificial ventilation but maintenanc e of the artificial airway
- C. Discontinuation of anxiolytic and pain medications
- D. Titration of ventilator support based upon blood gas de terminations
Correct Answer: B
Rationale: The correct answer is B because during terminal weaning, the artificial ventilation is discontinued while maintaining the artificial airway to ensure comfort and support. This allows the patient to breathe on their own with support as needed.
Explanation:
1. Option A: Complete extubation following ventilator withdrawal may not be suitable during terminal weaning as it involves removing the breathing tube entirely.
2. Option C: Discontinuation of anxiolytic and pain medications may not always be appropriate during terminal weaning as it depends on the patient's comfort needs.
3. Option D: Titration of ventilator support based on blood gas determinations is not typically done during terminal weaning as the focus is on gradual withdrawal of ventilation support while maintaining comfort.