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Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.)
- A. Environmental manipulation
- B. Explanations of monitoring equipment
- C. Guided imagery
- D. Music therapy
Correct Answer: A
Rationale: Step 1: Environmental manipulation involves adjusting factors like lighting, noise levels, and room temperature to create a soothing environment, which can help reduce pain and anxiety.
Step 2: By controlling the physical surroundings, patients may feel more comfortable and relaxed, leading to improved pain management and reduced anxiety levels.
Step 3: Explanations of monitoring equipment and guided imagery are not directly related to environmental changes that can impact pain and anxiety.
Step 4: Music therapy, while beneficial for some patients, is not categorized as environmental manipulation.
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The nurse is preparing to provide postmortem care for a patient who has just died. Which action should the nurse take first?
- A. Close the patient’s eyes and place a pillow under the head.
- B. Wash the patient’s body and apply a clean gown.
- C. Remove all medical equipment and tubes.
- D. Confirm that a death certificate has been signed.
Correct Answer: A
Rationale: Rationale:
A: Closing the patient's eyes and placing a pillow under the head is the first step in postmortem care to maintain dignity and prevent airway occlusion.
B: Washing the body and changing clothes can be done later and is not the priority.
C: Removing medical equipment can wait until after ensuring the patient's comfort.
D: Confirming the death certificate is important but not the immediate first step in postmortem care.
The nurse is assessing pain levels in a critically ill patient . The nurse recognizes that which patient action as indicatin g the greatest level of pain?
- A. Brow lowering
- B. Eyelid closing
- C. Grimacing
- D. Staring
Correct Answer: C
Rationale: Correct Answer: C (Grimacing)
Rationale:
1. Grimacing is a universal nonverbal sign of pain.
2. It involves facial muscles, indicating a high level of discomfort.
3. Brow lowering and eyelid closing are subtle signs, less indicative of severe pain.
4. Staring may signify concentration, not necessarily pain.
Summary:
Grimacing is the correct choice as it directly correlates with pain intensity, unlike the other options which are less specific or relevant indicators of severe pain.
As part of nursing management of a critically ill patient, o rders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from se dation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce thabei rrbi.csokm o/tef svt entilator-associated pneumonia. This group of evidence-based interventions is often referred to using what term?
- A. Bundle of care.
- B. Clinical practice guideline.
- C. Patient safety goal.
- D. Quality improvement initiative.
Correct Answer: A
Rationale: The correct answer is A: Bundle of care. A bundle of care refers to a set of evidence-based interventions that, when implemented together, have been shown to improve patient outcomes. In this scenario, keeping the head of the bed elevated, daily awakening from sedation, and oral care protocols are bundled together to reduce the risk of ventilator-associated pneumonia. This approach is based on the idea that implementing multiple interventions simultaneously is more effective than individual interventions alone.
Choices B, C, and D are incorrect because:
B: Clinical practice guidelines provide recommendations for healthcare providers based on evidence but do not necessarily involve a group of interventions bundled together.
C: Patient safety goals are specific objectives aimed at improving patient safety outcomes, but they do not specifically refer to a group of interventions bundled together.
D: Quality improvement initiatives focus on improving processes and outcomes in healthcare settings but do not necessarily involve a group of interventions bundled together for a specific purpose like in this case.
A patient who has been declared brain dead is considered a potential organ donor. In order to proceed with donation, the nurse must understand that applicable concept?
- A. A signed donor card mandates that organs be retrieved in the event of brain death.
- B. After brain death has been determined, perfusion and o xygenation of organs is maintained until organs can be removed in the operatin ag bi rbro .co omm /t. e st
- C. The healthcare proxy does not need to give consent for the retrieval of organs.
- D. Once a patient has been established as brain dead, life support is withdrawn and organs are retrieved.
Correct Answer: B
Rationale: The correct answer is B because after brain death is confirmed, maintaining perfusion and oxygenation of organs is crucial to ensure their viability for donation. This process allows organs to be retrieved in optimal condition during the operation. Choice A is incorrect because a signed donor card is not a legal mandate for organ retrieval. Choice C is incorrect as the healthcare proxy's consent is typically required for organ donation. Choice D is incorrect because life support is not immediately withdrawn upon brain death confirmation; instead, organ preservation measures are initiated.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
- A. Tracheostomy tube suctioning.
- B. Medication administration.
- C. Colostomy care instruction.
- D. Client personal hygiene.
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.